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 ["25"]
Explanation
To calculate the drops per minute for an IV infusion, we need to use the following formula:
gtt/min = (volume x drop factor) / time
In this case, the volume is 50 mL, the drop factor is 20 gtt/mL, and the time is 40 minutes. Plugging these values into the formula, we get:
gtt/min = (50 x 20) / 40
gtt/min = 1000 / 40
gtt/min = 25
Therefore, the adolescent patient should receive 25 drops per minute of Cefazolin IV.
Correct Answer is B
Explanation
A. Teaching the child to take long, slow breaths:
While teaching slow breathing techniques can be helpful in managing anxiety and promoting a sense of calm, it may not directly address the underlying airway inflammation and bronchodilation needed in acute laryngotracheobronchitis.
B. Assisting with racemic epinephrine nebulizer therapy:
Racemic epinephrine is a medication that contains epinephrine, a bronchodilator. Nebulizer therapy with racemic epinephrine helps reduce airway inflammation, allowing for bronchodilation and improved breathing. This is a common intervention for managing acute respiratory distress in conditions like croup.
C. Administering an oral analgesic:
Oral analgesics, such as pain medications, can provide relief from discomfort or pain, but they do not directly address the bronchodilation needed for conditions like acute laryngotracheobronchitis.
D. Administering a corticosteroid:
Corticosteroids have anti-inflammatory properties and can help reduce swelling and inflammation in the airways. By doing so, they contribute to bronchodilation and improved breathing in conditions like croup. Corticosteroids are often used as part of the treatment plan for acute laryngotracheobronchitis.
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