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 B
Explanation
A. The heart triples in size over the first year of lifE. While cardiac growth occurs during infancy, the described change is not specific to a developmental milestone.
B. Most infants triple their birth weight by 4 to 6 months of age and quadruple their birth weight by the time they are 1 year olD. This statement accurately describes a significant developmental milestone related to physical growth during infancy.
C. By 6 months of age, the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth: This statement describes brain growth rather than a
milestone related to physical growth or development.
D. The head circumference increases rapidly during the first 6 months: the average increase is about 1 in per month: While head circumference growth is important, it does not specifically relate to the described developmental milestone of weight gain during infancy.
Correct Answer is A
Explanation
A. Most infants double their birth weight by 5 to 6 months of age.
B. Doubling of birth weight by 3 months is less common and may indicate overfeeding or an error in measurement.
C. By 9 months, infants have usually surpassed the milestone of doubling their birth weight.
D. At 12 months, infants typically triple their birth weight, so this is beyond the timeframe for doubling birth weight
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