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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Inability to make audible voice sounds:

This symptom is more indicative of conditions affecting the vocal cords or larynx, such as laryngitis. Tonsillitis primarily involves inflammation of the tonsils and may not directly impact the ability to make audible voice sounds.

B. Erythema of the pharynx:

Erythema (redness) of the pharynx is a common manifestation of tonsillitis. Inflammation of the tonsils and surrounding areas can lead to redness and swelling in the throat.

C. Bark-like cough:

A bark-like cough is often associated with croup, which involves inflammation of the larynx and trachea, not the tonsils. It is a distinct condition from tonsillitis.

D. Hoarseness:

Hoarseness can be a symptom of various conditions affecting the vocal cords or larynx, but it is not a typical manifestation of tonsillitis. Tonsillitis is more commonly associated with sore throat, difficulty swallowing, and erythema of the pharynx.

A. high sodium chloride concentration in the sweat. B. chronic lack of oxygen. C. decreased respiratory capacity. D. impaired digestive activity.

Correct Answer is B

Explanation

A.While cystic fibrosis is characterized by a high concentration of sodium chloride in sweat due to defective chloride channels, this is not the cause of the barrel chest and clubbing of the fingers.

B.The barrel chest and clubbing of the fingers are often seen in children with cystic fibrosis due to chronic hypoxia (lack of oxygen). Chronic lung infections, airway obstruction, and respiratory insufficiency associated with cystic fibrosis lead to prolonged low oxygen levels, which can result in these physical changes.

C.Decreased respiratory capacity, often due to the chronic respiratory issues associated with cystic fibrosis, can result in a barrel chest (increased chest diameter due to air trapping) and clubbing of the fingers (a sign of chronic hypoxia).

D.Decreased respiratory capacity (due to thick mucus and airway obstruction) does contribute to chronic respiratory issues in cystic fibrosis, but the direct cause of the barrel chest and clubbing is the chronic lack of oxygen (hypoxia) rather than decreased capacity alone. The changes in the chest and fingers are a result of prolonged oxygen deprivation.

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The nurse is performing a physical assessment on a 6-month-old baby. Which finding should the nurse understand as abnormal for this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting data on a child with a diagnosis of tonsillitis. Which clinical manifestation would likely have been noted in the child with this diagnosis?

Correct Answer is B

Explanation

The student nurse is collecting data on a child diagnosed with cystic fibrosis and notes the child has a barrel chest and clubbing of the fingers. In explaining this manifestation of the disease, the staff nurse explains the cause of this symptom to be:

Correct Answer is B

Explanation

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