A nurse is assessing a female child in an area struck by an earthquake. The child, who is crying, walks well, can state her first name, and repeatedly says "All done" and "Go bye-bye” now during the assessment. The child has 24 deciduous teeth and her anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old?
24
12
18
30
The Correct Answer is D
Walking Well: The ability to walk well typically develops around 12 to 15 months. Since the child walks well, we can consider her closer to this age range.
Stating first name: By 24-30 months, most children can identify themselves by name.
Repeating Phrases (“All done” and “Go bye-bye”): Repeating phrases is common around 15 to 18 months. The child’s language development aligns with this stage.
24 Deciduous Teeth: By the age of 2 to 3 years, children typically have all 20 deciduous (baby) teeth. Since this child has 24 deciduous teeth, she is likely closer to the 2-year-old mark.
Closed Anterior Fontanel: The anterior fontanel (soft spot on the baby’s head) usually closes by 18 months. The fact that it is closed indicates that the child is beyond this age.
Child is most likely 30 months old.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. It’s usually best to build trust and rapport first with non-invasive assessments. Starting with a potentially uncomfortable procedure like looking in the ears may cause distress and make the rest of the exam more difficult.
B.Examining the tympanic membrane before the head and neck might still be too early in the assessment and could cause the child to become uncooperative for subsequent steps. If the child becomes upset, it could complicate the rest of the physical exam, making it harder to complete.
C.Performing the ear examination at the end allows the nurse to build trust and rapport throughout the visit. The child is less likely to become distressed too early in the exam, which helps maintain cooperation for as long as possible.If the child does become upset, it is at the end of the visit, and the more critical assessments have already been completed.
D.If the ear exam causes distress, it may make the child uncooperative for important assessments like auscultating the heart and lungs.
Correct Answer is B
Explanation
While the newborn's heart rate of 170 bpm is elevated, the respiratory rate of 44 breaths/min, blood pressure of 85/52 mmHg, and temperature of 99°F (37.2°C) are within the normal range for a newborn.
It is important for the nurse to explain to the parents that the newborn's heart rate may be elevated due to the vomiting and dehydration and that healthcare providers will monitor the vital signs closely to ensure the newborn's stability.
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