The nurse is performing a physical assessment on a 6-month-old baby. Which finding should the nurse understand as abnormal for this child?
The child has the beginning signs of tooth eruption.
The child is able to track and follow objects.
The child’s anterior fontanel is open.
The child’s posterior fontanel is open.
The Correct Answer is D
A. The child has the beginning signs of tooth eruption:
Teething usually begins around 4-7 months of age, so the beginning signs of tooth eruption (teething) are typical at six months.
B. The child is able to track and follow objects:
By six months, most infants can track and follow objects with their eyes, which is a normal developmental milestone for this age.
C. The child’s anterior fontanel is open:
The anterior fontanelle, the soft spot at the top of the baby's head, remains open until around 18-24 months of age, so its presence at six months is expected and considered normal.
D. The child’s posterior fontanel is open.
By six months of age, the posterior fontanelle, the soft spot located at the back of the baby's head, typically closes or is significantly smaller than it was at birth. The posterior fontanelle usually closes between 2 to 4 months of age in most infants. If it remains noticeably open by six months, it might warrant further evaluation as it could be indicative of a developmental or medical issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The mother opens the capsule and some medication spills on the fingers:
Pancreatic enzymes are usually taken intact, and their contents are meant to be sprinkled on soft food, not opened and spilled. This observation suggests a misunderstanding of the proper administration.
B. The child takes a dose before having an afternoon snack.
In cystic fibrosis, pancreatic enzyme replacement therapy is commonly used to help digest and absorb nutrients. The enzymes are typically taken with meals and snacks to aid in the digestion of food.
C. The child chews an enteric form of the medication:
Pancreatic enzymes are usually enteric-coated to protect them from stomach acid, and they are not meant to be chewed. Chewing can reduce their effectiveness. This observation indicates a need for clarification on administration.
D. The father tells the child that diarrhea is expected with this medication:
While gastrointestinal side effects can occur with pancreatic enzyme use, persistent diarrhea may indicate a dosage issue or other problems. It's important to address this with the healthcare provider. The statement suggests a potential misunderstanding or need for clarification.
Correct Answer is ["-195"]
Explanation
The water intake is half of 900 mL, which is 450 mL. The soft drink intake is 12 oz, which is equivalent to 355 mL. Therefore, the total fluid intake is 450 + 355 = 805 mL.
The urine output is the sum of the two voids, which is 600 + 350 = 950 mL. The drainage output is 50 mL. Therefore, the total fluid output is 950 + 50 = 1000 mL.
The net I/O is the difference between the fluid intake and output, which is 805 - 1000 = -195 mL. This means that the patient had a negative fluid balance of 195 mL during the night.
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