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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Auscultation B. Deep palpation C. Inspection D. Superficial palpation

Correct Answer is C,A,D,B

Explanation

Correct Answer:C, A, D, B.

C. Inspection:The initial step in an abdominal assessment is to inspect the abdomen visually. This allows the nurse to observe for any abnormalities in skin color, shape, and

movement without causing discomfort or altering findings that could be affected by palpation or auscultation.

A. Auscultation:Following inspection, auscultation is performed before any palpation. This is because palpation can stimulate bowel sounds, which may alter the nurse's ability to accurately assess the bowel activity and vascular sounds.

D. Superficial palpation:After auscultation, superficial palpation is done to detect tenderness, distension, or superficial masses. It is gentle and less likely to cause discomfort or alter deeper structures.

B. Deep palpation: The final step is deep palpation, which is used to examine the organs and structures that are deeper within the abdominal cavity. It is performed last to prevent any potential discomfort or alteration in the patient's condition that could interfere with the earlier steps of the assessment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,A,D,B

Explanation

The nurse is teaching a new mother about the development of sensory skills in her newborn. What would alert the mother to a sensory deficit in her child?

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.)

The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?

The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?

The nurse is caring for a 7-month-old girl during a well-child visit. Which intervention is most appropriate for this child?

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

When describing the various changes that occur in organ systems during adolescence, what would the nurse include?