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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Congenital anomalies: While congenital anomalies can contribute to infant mortality, they are not the leading cause of death among infants.
B. Respiratory distress: Respiratory distress can be a significant concern in newborns, especially premature infants, but it is not the leading cause of death among infants overall.
C. Low birth weight: Low birth weight is a risk factor for various health complications in infants, but it is not the leading cause of death among infants.
D. Sudden infant death syndrome (SIDS): SIDS is the sudden and unexplained death of an otherwise healthy infant, typically during sleep. It is the leading cause of death among infants aged 1 month to 1 year, making it an essential consideration in health promotion and education efforts for parents.
Correct Answer is C
Explanation
A. Height in girls increases rapidly after menarche and usually ceases immediately after
menarchE. Height increases during adolescence are not directly related to menarche. Growth in girls typically continues for several years after menarche, although at a slower rate compared to the pre-pubertal growth spurt.
B. Boys' growth spurts usually begin between the ages of 8 and 14 years and end between the ages of 13½ and 17½ years: While boys do experience a growth spurt during adolescence, the timing and duration of growth spurts can vary widely among individuals. Growth typically
continues beyond the age of 14, with some boys reaching their full adult height in their late teens or early twenties.
C. Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarchE. Peak height velocity refers to the period of most rapid growth during adolescence. In girls, PHV typically occurs around the age of 12, with growth continuing for some time after menarche.
D. Boys reach PHV and peak weight velocity (PWV) at about 16 years of agE. Boys generally experience PHV and PWV later than girls, typically occurring around the age of 14 to 16. These milestones mark the period of most rapid growth in boys, with height and weight increasing significantly during this time.
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