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 A
Explanation
A. Apical; For infants and young children under 2 years of age, the apical pulse is the most accurate and reliable site for assessing heart rate because peripheral pulses can be difficult to palpate and may not reflect true cardiac activity.
B. Radial pulse is not as reliable in children under 2 years old because it can be weak and hard to detect.
C. Carotid pulse is typically used in emergency situations (like assessing circulation during CPR) and is not ideal for routine vital signs in infants due to the risk of compressing the airway.
D. Femoral pulse may be used to assess circulation in the lower extremities but is not the best choice for measuring pulse rate.
Correct Answer is D
Explanation
A. Calling social work immediately is premature and dismissive of the mother's concerns without first assessing the situation.
B. Reviewing Elsie's admission history is important but does not address the immediate concern or the mother’s feelings.
C. Seeing Elsie last may delay care and worsen the mother’s anxiety.
D. Going and discussing the mother's concerns as soon as possible is the best action. It shows respect, builds trust, allows for early assessment, and helps address any potential issues promptly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.