A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?

Increased intracranial pressure

Dehydration

Overhydration

These are normal findings

Answer and Explanation

The Correct Answer is D

A. Increased intracranial pressurE. Pulsation and bulging of the fontanel may be signs of

increased intracranial pressure in infants. However, it is important to differentiate between normal fontanel characteristics and abnormal signs of elevated intracranial pressure. In this case, the pulsation and bulging are likely normal responses to crying and changes in intracranial pressure during the newborn period.

B. Dehydration: Dehydration typically presents with sunken fontanels rather than pulsation and bulging. Dehydration is a serious condition that requires prompt assessment and intervention, but it is not indicated by the findings described in the scenario.

C. Overhydration: Overhydration is not typically associated with pulsation and bulging of the fontanel. Overhydration may lead to fluid overload and edema but does not directly affect fontanel characteristics.

D. These are normal findings: Pulsation and brief bulging of the fontanel in response to crying are considered normal findings in newborns. Fontanels allow for the flexibility of the skull bones during childbirth and provide space for brain growth during infancy. Pulsation and bulging may occur temporarily during crying or changes in intracranial pressure and are not necessarily

indicative of pathology.

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Correct Answer is C

Explanation

A. Transduction - Transduction refers to the process of reasoning from one specific instance to another without necessarily understanding the broader concept. The girl's statement about the sky and her throat does not demonstrate this mental process.

B. Centration - Centration involves focusing on only one aspect of a situation while ignoring others. The girl's statement may involve a degree of focus, but it's more indicative of a broader imaginative process.

C. Magical thinking - Magical thinking involves attributing human emotions or characteristics to inanimate objects or natural phenomena. The girl's belief that the sky is crying because it's sad about her throat hurting reflects this type of thinking.

D. Animism - Animism is a belief system that attributes life or consciousness to natural objects or phenomena. While the girl's statement involves anthropomorphizing the sky, it specifically

involves emotions rather than attributing life itself to the sky. Therefore, magical thinking is a more accurate description.

A. "Activity will increase the respiratory rate." B. "The rate and rhythm of breath are irregular in newborns." C. "Newborns are abdominal breathers." D. "Newborns do not expand their lungs fully with each respiration."

Correct Answer is B

Explanation

A. "Activity will increase the respiratory rate": While activity can indeed affect respiratory rate, counting for a full minute allows for a more accurate assessment of the newborn's baseline respiratory rate, regardless of activity level.

B. "The rate and rhythm of breath are irregular in newborns": This statement reflects an understanding of why a complete minute is necessary for counting the respiratory rate in newborns. Newborns often have irregular breathing patterns, so counting for a full minute helps ensure an accurate assessment of their respiratory rate.

C. "Newborns are abdominal breathers": While newborns primarily use their diaphragm to

breathe (abdominal breathing), this fact alone does not explain why the respiratory rate should be counted for a full minute.

D. "Newborns do not expand their lungs fully with each respiration": While newborns may not fully expand their lungs with each breath, this factor is not the primary reason for counting the respiratory rate for a full minute.

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A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?

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The nurse is caring for a 5-year-old girl post-tonsillectomy. The girl looks out the window and tells the nurse that it is raining and says. The sky is crying because it is sad that my throat hurts." The nurse understands that the girl is demonstrating which mental process?

Correct Answer is C

Explanation

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

Correct Answer is B

Explanation

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