A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the cornerof the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?

An anxiety reaction

Regression

Resentment toward the mother

Developing autonomy

Answer and Explanation

The Correct Answer is A

A. An anxiety reaction: The toddler's behavior of sitting quietly, sucking her thumb, and turning away from the nurse when approached after her mother leaves the room suggests anxiety. These

behaviors are common signs of distress or discomfort in young children, especially when separated from their primary attachment figure (in this case, the mother).

B. Regression: Regression involves reverting to earlier, more immature behaviors in response to stress or discomfort. While thumb sucking can be considered a form of regression, the behavior observed in this scenario is more indicative of anxiety rather than a broader regression in

developmental milestones.

C. Resentment toward the mother: There is no evidence in the scenario to suggest that the toddler is expressing resentment toward the mother. The behaviors observed are more likely related to

the child's emotional response to separation and hospitalization.

D. Developing autonomy: Developing autonomy typically involves asserting independence and exploring one's environment. The behaviors observed in the scenario are more indicative of anxiety and distress rather than autonomous behavior.

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Correct Answer is C

Explanation

A. Height in girls increases rapidly after menarche and usually ceases immediately after

menarchE. Height increases during adolescence are not directly related to menarche. Growth in girls typically continues for several years after menarche, although at a slower rate compared to the pre-pubertal growth spurt.

B. Boys' growth spurts usually begin between the ages of 8 and 14 years and end between the ages of 13½ and 17½ years: While boys do experience a growth spurt during adolescence, the timing and duration of growth spurts can vary widely among individuals. Growth typically

continues beyond the age of 14, with some boys reaching their full adult height in their late teens or early twenties.

C. Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarchE. Peak height velocity refers to the period of most rapid growth during adolescence. In girls, PHV typically occurs around the age of 12, with growth continuing for some time after menarche.

D. Boys reach PHV and peak weight velocity (PWV) at about 16 years of agE. Boys generally experience PHV and PWV later than girls, typically occurring around the age of 14 to 16. These milestones mark the period of most rapid growth in boys, with height and weight increasing significantly during this time.

A. Increased intracranial pressure B. Dehydration C. Overhydration D. These are normal findings

Correct Answer is D

Explanation

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.

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Naxlex Comprehensive Predictor Exams

The school nurse is performing health assessments on students in middle school. Of what developmental milestone should the nurse be aware?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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