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. Is beginning to tie her own shoelaces: The ability to begin tying shoelaces is a fine motor skill milestone that is typically achieved around 5 to 6 years of age. This finding indicates appropriate motor skill development.

B. Can copy a square on another piece of paper: Copying shapes is a visual-motor integration skill that develops during early childhood. The ability to copy a square is an appropriate

milestone for a 5-year-old.

C. Draws a person with three body parts: By age 5, most children can draw a person with more body parts, typically including a head, trunk, arms, legs, and facial features. Drawing a person with only three body parts may suggest a delay in fine motor or cognitive development and could be a cause for concern.

D. Can dress and undress herself without help: Independence in dressing and undressing is a self- care skill that is typically achieved by 5 years of age and indicates appropriate motor

development.

A. "This is normal behavior for infants unless the stool passed is black or green." B. "This is normal behavior for infants due to the immaturity of the gastrointestinal system." C. "This is normal behavior for infants unless the stool passed is hard and dry." D. "This indicates a blockage in the intestine and must be reported to the health care provider."

Correct Answer is B

Explanation

A. "This is normal behavior for infants unless the stool passed is black or green.": While black or green stools may indicate potential issues, grunting and crying during bowel movements are common behaviors in infants and are not necessarily indicative of a problem.

B. "This is normal behavior for infants due to the immaturity of the gastrointestinal system.": Grunting and crying during bowel movements are typical behaviors in infants, especially during the first few months of life. This is because the infant's gastrointestinal system is still developing and they may have difficulty coordinating their muscles to pass stool smoothly.

C. "This is normal behavior for infants unless the stool passed is hard and dry.": While hard and dry stools may indicate constipation, grunting and crying during bowel movements can still be normal behaviors in infants, regardless of the consistency of the stool.

D. "This indicates a blockage in the intestine and must be reported to the health care provider.": Grunting and crying during bowel movements are not necessarily indicative of a blockage in the intestine. These behaviors are common in infants and usually resolve as the infant's gastrointestinal system matures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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