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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
The correct answers are Choices A and C.
Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.
Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.
Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.
Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.
Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.
Correct Answer is A
Explanation
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