While performing physical assessment of a 6-month-old, the nurse notes that the infant's anterior fontanel is still slightly open. Which of the following is the nurse's most appropriate action?
Notify the physician immediately because there is a problem.
Perform an intensive neurologic examination.
Perform an intensive developmental examination.
Do nothing because this is a normal finding for the age.
The Correct Answer is D
A. An open anterior fontanel at 6 months is generally normal and does not require immediate notification.
B. An intensive neurologic exam is not necessary unless other abnormal signs are present.
C. Developmental exam may be part of routine assessment but is not specifically required just because the fontanel is open.
D. The anterior fontanel normally remains open until about 12-18 months of age, so a slightly open fontanel at 6 months is expected and considered normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. At 8 weeks (about 2 months), infants typically start some head control but are not yet rolling from back to belly.
B. At 2 months, rolling over usually has not started.
C. Rolling from back to belly typically develops around 5 to 6 months of age as gross motor skills improve.
D. By 10 months, rolling is well established and infants are usually sitting, crawling, or standing.
Correct Answer is C
Explanation
A. The gluteus maximus is not recommended for infants due to the risk of injury to the sciatic nerve.
B. The deltoid muscle is too small in infants for safe IM injections.
C. The vastus lateralis (anterolateral thigh) is the preferred site for IM injections in infants because it is well-developed and free of major nerves or blood vessels.
D. The vastus medialis is not commonly used for IM injections in infants.
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