A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
Natural loss of deciduous teeth
Nontender, protruding abdomen
Palpable fontanels
Head circumference exceeds chest circumference
The Correct Answer is B
A. Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B. Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C. Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D. Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A sore throat is a common and expected finding after a tonsillectomy due to irritation from the procedure. While it can cause discomfort, it is not a priority concern unless it worsens significantly or is accompanied by other symptoms indicating complications such as bleeding or infection.
Choice B rationale:
Frequent swallowing can be a sign of bleeding after a tonsillectomy. The child may swallow more often to clear blood or blood clots from the throat, which could indicate that there is active bleeding from the surgical site.
Choice C rationale:
Blood-tinged mucus is a common finding in the immediate postoperative period after a tonsillectomy. It is expected due to the healing process and is not a cause for concern unless it becomes profuse or is accompanied by active bleeding.
Choice D rationale:
While dark brown vomit may indicate that the child has swallowed blood, it is not as immediately concerning as frequent swallowing, which could suggest active bleeding at the surgical site. Dark brown emesis is typically less alarming, but it should still be monitored closely.
Correct Answer is C
Explanation
A. Incorrect. Temporarily discontinuing the TPN infusion may result in an abrupt decrease in the client's glucose intake, which could lead to hypoglycemia.
B. Incorrect. Giving lactated Ringer's solution would not address the client's TPN needs and may also affect electrolyte balance.
C. Administering dextrose 10% in water wouldprovide the required glucosed as the next bag is awaited
D. Slowing the TPN infusion rate can help stretch the remaining volume until a new bag becomes available. However, it does not adress the body's glucose requirements.
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