A nurse is caring for a toddler who is 24 months of age during a well-child clinic visit. Which of the following is an expected finding?
Ocular strabismus
Slightly bowed legs
Thoracic breathing pattern
Anterior fontanelle less than 1 cm
The Correct Answer is B
Choice A reason: Ocular strabismus (crossed eyes) is not expected at 24 months. By this age, ocular alignment should be normal. Persistent strabismus beyond 6 months of age requires evaluation for possible vision problems.
Choice B reason: Slightly bowed legs are expected in toddlers due to normal physiologic development. This finding is common as children transition from crawling to walking and usually resolves by age 3 to 4 years. It is considered a normal variation at 24 months.
Choice C reason: Toddlers at 24 months should demonstrate an abdominal breathing pattern, not thoracic. Thoracic breathing is more characteristic of older children and adults. Therefore, this finding would not be expected.
Choice D reason: The anterior fontanelle typically closes between 12 and 18 months. At 24 months, it should already be closed. An anterior fontanelle less than 1 cm at this age would be abnormal and suggest delayed closure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Chest pain in a client with a recent myocardial infarction is a priority because it may indicate ongoing ischemia or reinfarction. Even moderate pain (rated 4/10) requires immediate assessment and intervention to prevent life-threatening complications. This makes option A the correct answer.
Choice B reason: A temperature of 38.3° C (101° F) in a client with AIDS and pneumonia is concerning but not immediately life-threatening. This client requires monitoring and treatment, but the situation is less urgent than chest pain in a post-MI client.
Choice C reason: An oxygen saturation of 89% in a client with COPD is below normal but may be expected in advanced disease. While this requires intervention, it is not as immediately critical as chest pain in a post-MI client.
Choice D reason: Inability to void in a client with pelvic inflammatory disease is uncomfortable and requires evaluation, but it is not immediately life-threatening. This option is lower priority compared to acute cardiac symptoms.
Correct Answer is A
Explanation
Choice A reason: Prolonged uterine contractions lasting 90 seconds indicate uterine tachysystole, a dangerous adverse effect of oxytocin. This can reduce placental perfusion, compromise fetal oxygenation, and increase risk of uterine rupture. Immediate intervention is required.
Choice B reason: Moderate variability of the fetal heart rate is a reassuring sign of adequate oxygenation and intact neurological function. It is not an adverse effect.
Choice C reason: Contractions every 2 minutes are within the normal therapeutic range for oxytocin augmentation. This frequency supports labor progression without compromising fetal well-being.
Choice D reason: A fetal heart rate of 150/min is within the normal baseline range (110–160/min). This is not an adverse effect.
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