A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
Anterior fontanel closed
Plays with toes
Posterior fontanel closed
Moves objects to mouth
The Correct Answer is A
The correct answer is A. Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old
infant and do not require notification of the provider.
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Correct Answer is C
Explanation
Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.
Correct Answer is A
Explanation
The correct answer is A. Promoting trust. Trust is essential for establishing a therapeutic relationship with the client and facilitating their recovery. The nurse demonstrates trustworthiness by responding to the client's needs in a timely and respectful manner, and by providing them with a healthy meal that meets their nutritional requirements.
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