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 A

Explanation

A. Measles, Mumps, and Rubella (MMR):

The first dose of the MMR vaccine is usually administered around 12-15 months of age. Therefore, this vaccine is appropriate for a 15-month-old child's routine health visit.

B. Pneumococcal:

The pneumococcal vaccine is typically given in several doses, with one of the doses recommended around 12-15 months. It's part of the routine immunization schedule for this age range.

C. Meningococcal:

Meningococcal vaccines are not usually part of the routine schedule at 15 months of age unless there are specific risk factors or circumstances that necessitate this vaccination.

D. Rotavirus (RV):

The rotavirus vaccine is administered in multiple doses, usually starting at around 2 months and completing before 8 months of age. By 15 months, the child should have completed the recommended doses.

A. Preventing spread of infection B. Maintaining skin integrity C. Improving nutrition D. Promoting comfort

Correct Answer is A

Explanation

A. Preventing spread of infection:

This is a priority because individuals with acquired immunodeficiency syndrome (AIDS) have a compromised immune system. Preventing the spread of infections is crucial to avoid additional complications and safeguard the individual's health.

B. Maintaining skin integrity:

Skin integrity is important for overall health, but in the context of AIDS, preventing infections and promoting immune function take precedence over maintaining skin integrity. Skin issues might be secondary to the immune system's compromised state.

C. Improving nutrition:

Good nutrition is important for overall health, including supporting the immune system. However, preventing the spread of infection is more immediate and critical in the case of someone with AIDS. Addressing nutritional needs can be part of the overall care plan but might be secondary to preventing infections.

D. Promoting comfort:

While promoting comfort is essential in nursing care, the priority in the case of a child with AIDS would be preventing the spread of infection due to the immunocompromised state. Comfort measures may be incorporated into the care plan, but they would not take precedence over preventing further health complications.

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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

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