A nurse is assessing the fontanels of an 8-month-old infant.
Which of the following findings should the nurse recognize as an expected finding?

The anterior fontanel is open.

The posterior fontanel is open.

Both fontanels show molding.

Both fontanels are the same size.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The anterior fontanel is open in an 8-month-old infant. The anterior fontanel, located at the top of the baby's head where the skull bones have not yet fused, typically closes between 12 to 18 months of age. It is a normal finding in an 8-month-old infant.

Choice B rationale:

The posterior fontanel closes earlier than the anterior fontanel, usually within the first few months of life. It is a smaller diamond-shaped area located at the back of the baby's head. It is not expected to be open in an 8-month-old infant.

Choice C rationale:

Molding refers to the shaping of the fetal head during passage through the birth canal. It can cause temporary changes in the shape of the baby's skull. By 8 months of age, molding is not an expected finding as the skull bones have had time to return to their normal shape.

Choice D rationale:

Both fontanels being the same size is not a typical finding. The anterior fontanel is larger than the posterior fontanel, and their sizes are proportional. Any significant deviation from this proportion could indicate abnormal skull development and should be further assessed.

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Correct Answer is B

Explanation

The correct answer is: b: Perform the procedure prior to meals.

Choice A rationale: The rationale for Choice A involves understanding the technique of percussion in postural drainage for cystic fibrosis management. Percussion is a component of chest physiotherapy that involves rhythmic clapping or tapping on the chest wall to help loosen and mobilize secretions within the airways. However, holding the hand flat during percussion may not effectively transmit the necessary force to the chest wall for optimal secretion mobilization. Instead, cupping the hands allows for better resonance and transmission of percussion force, enhancing the effectiveness of the procedure.

Choice B rationale: Performing postural drainage prior to meals is the recommended timing for several reasons. Firstly, initiating the procedure before meals allows the child's stomach to be relatively empty, reducing the risk of discomfort, nausea, or vomiting during the procedure. Secondly, performing postural drainage before meals helps prevent aspiration of stomach contents, which can occur if the child vomits during or after the procedure. Aspiration poses significant risks, including lung infection and respiratory distress, particularly in individuals with compromised respiratory function such as those with cystic fibrosis.

Choice C rationale: While bronchodilators may play a role in managing airway obstruction in cystic fibrosis, administering them after postural drainage is not a standard practice. Bronchodilators are typically used to alleviate bronchoconstriction and improve airflow in the lungs. However, their administration after postural drainage may not be directly related to the immediate goals of the procedure, which are to mobilize and clear pulmonary secretions. The timing of bronchodilator administration is often guided by the individual's clinical condition and the presence of symptoms such as wheezing or shortness of breath.

Choice D rationale: Performing postural drainage twice daily may not provide adequate frequency for managing secretions in individuals with cystic fibrosis. The goal of postural drainage is to facilitate the removal of thick, tenacious mucus from the airways to improve respiratory function and reduce the risk of complications such as infections. In cystic fibrosis, mucus clearance is essential for maintaining pulmonary health and preventing exacerbations. Therefore, a more frequent regimen, often including multiple sessions of postural drainage per day, may be necessary to achieve optimal therapeutic outcomes and prevent mucus accumulation and airway obstruction.

A. Assess for urinary retention. B. Encourage the client to turn from side to side. C. Monitor for elevated temperature. D. Inform the client to expect drowsiness. E. Assist the client with ambulation.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

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A nurse is assessing the fontanels of an 8-month-old infant.Which of the following findings should the nurse recognize as an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

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A nurse is assessing the fontanels of an 8-month-old infant.
Which of the following findings should the nurse recognize as an expected finding?