Which of the following findings is concerning to the nurse?
Absence of tears when the infant cries
Presence of vernix caseosa at delivery
Presence of anterior and posterior fontanels
Absence of the rooting reflex
The Correct Answer is D
Choice A reason: This is not a concerning finding for the nurse. Absence of tears when the infant cries is normal and expected in the first few months of life. The tear ducts and glands are not fully developed yet, and the infant does not produce enough tears to moisten the eyes or overflow the eyelids. The nurse should monitor the infant's hydration and eye health, but should not be alarmed by the absence of tears.
Choice B reason: This is not a concerning finding for the nurse. Presence of vernix caseosa at delivery is normal and expected in newborns, especially those born before 40 weeks of gestation. Vernix caseosa is a white, cheesy substance that covers the skin of the fetus in the womb. It protects the skin from the amniotic fluid and helps with temperature regulation and infection prevention. The nurse should gently wipe off the excess vernix caseosa, but should not try to remove it completely.
Choice C reason: This is not a concerning finding for the nurse. Presence of anterior and posterior fontanels is normal and expected in infants. Fontanels are soft spots on the skull where the bones have not yet fused together. They allow the skull to be flexible and accommodate the growing brain. The nurse should palpate the fontanels gently and assess their size, shape, and tension, but should not be worried by their presence.
Choice D reason: This is the concerning finding for the nurse. Absence of the rooting reflex is abnormal and unexpected in infants. The rooting reflex is an involuntary movement or response that the infant makes when the cheek or mouth is touched. The infant turns the head and opens the mouth, seeking the source of stimulation. The rooting reflex is essential for breastfeeding and feeding in general. The nurse should assess the infant's neurological status and consult with the physician if the rooting reflex is absent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the most significant factor. The client's popularity may change over time or depend on external factors. The client may also face peer pressure or bullying from their friends.
Choice B reason: This is not the most significant factor. The client's academic performance may vary depending on the difficulty of the subjects, the quality of the teachers, or the availability of resources. The client may also experience stress or anxiety from the expectations of their parents or teachers.
Choice C reason: This is the best answer. The client's self-esteem is the most important factor that will help them cope with negative stressors. Self-esteem is the degree to which the client values and respects themselves. A positive self-esteem will enable the client to have confidence, resilience, and optimism in facing challenges and opportunities.
Choice D reason: This is not the most significant factor. The client's family support may be beneficial, but it may not be enough to protect them from negative stressors. The client may also have conflicts or disagreements with their siblings.
Correct Answer is A
Explanation
Choice A reason: This is the best answer. Eating disorders are more likely to develop during adolescence and young adulthood, which are the ages 12 to 20. This is because this is a period of rapid physical, mental, and emotional changes, as well as social and academic pressures. Adolescents and young adults may experience low self-esteem, body dissatisfaction, peer influence, or family conflict, which can contribute to the development of eating disorders.
Choice B reason: This is not the correct answer. Eating disorders can occur at any age, but they are less common in adults than in adolescents and young adults. Adults who develop eating disorders may have a history of eating disorders in their youth, or they may face new stressors or transitions that trigger their eating disorder. However, the risk for eating disorders is lower in adults than in adolescents and young adults.
Choice C reason: This is not the correct answer. Eating disorders are rare in middle-aged and older adults, which are the ages 35 to 65. This is because this is a period of stability and maturity, as well as acceptance and adaptation. Middle-aged and older adults may have more coping skills, resilience, and support, which can protect them from developing eating disorders.
Choice D reason: This is not the correct answer. Eating disorders are very rare in older adults, which are the ages 65 and older. This is because this is a period of decline and loss, as well as wisdom and dignity. Older adults may have less concern about their appearance, weight, or food, which can prevent them from developing eating disorders.
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