A nurse is assessing a 2-year-old toddler.
Which of the following findings should the nurse expect?
Nontender, protruding abdomen.
Head circumference exceeds chest circumference.
Palpable fontanels.
Natural loss of deciduous teeth.
The Correct Answer is A
A non-tender, protruding abdomen is a normal finding for a 2- year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.
Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.
Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by the age of 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.
Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A thoracentesis is a procedure that involves inserting a needle into the pleural space to remove excess fluid or air. Coughing can increase the risk of pneumothorax (collapsed lung) or bleeding during the procedure.
Choice B is wrong because the client does not need to be NPO (nothing by mouth) for 6 hr prior to the procedure. There is no risk of aspiration during a thoracentesis.
Choice C is wrong because the client should be positioned on the unaffected side for 4 hr following the procedure. This allows the affected lung to re-expand and prevents fluid from accumulating in the pleural space again.
Choice D is wrong because the client should not be placed in the prone position during the procedure. The prone position makes it difficult to access the pleural space and can compromise breathing.
Correct Answer is C
Explanation
According to the flashcards from Quizlet, a nurse should monitor a client who is at 33 weeks of gestation following an amniocentesis for contractions, as they are a sign of preterm labor and possible uterine rupture. An amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for testing. It can cause complications such as bleeding, infection, leakage of fluid, and injury to the fetus or placenta.
Choice A is wrong because it is not a common complication of amniocentesis.
Epigastric pain is more likely to be associated with preeclampsia, a condition that causes high blood pressure and proteinuria in pregnancy. Epigastric pain can indicate severe preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which are life- threatening complications that require immediate medical attention.
Choice B is wrong because it is not a direct result of amniocentesis.
Hypertension can occur in pregnancy due to various factors, such as chronic hypertension, gestational hypertension, preeclampsia, or eclampsia. Hypertension can increase the risk of complications such as placental abruption, fetal growth restriction, preterm birth, and maternal stroke.
Choice D is wrong because it is not a typical complication of amniocentesis.
Vomiting can occur in pregnancy due to various causes, such as morning sickness, gastroenteritis, food poisoning, or hyperemesis gravidarum. Vomiting can lead to dehydration, electrolyte imbalance, weight loss, and malnutrition if not treated properly.
Some normal ranges that are relevant for this question are:
- The normal gestational age for delivery is between 37 and 42 weeks.
A baby born before 37 weeks is considered preterm and may have complications such as respiratory distress syndrome, bleeding in the brain, infection, or low blood sugar.
- The normal fetal heart rate is between 110 and 160 beats per minute.
A fetal heart rate below 110 or above 160 can indicate fetal distress or hypoxia.
- The normal amniotic fluid index (AFI) is between 8 and 18 cm.
An AFI below 5 cm is considered oligohydramnios and can indicate fetal growth restriction, kidney problems, or rupture of membranes.
An AFI above 24 cm is considered polyhydramnios and can indicate fetal anomalies, diabetes mellitus, or Rh incompatibility.
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