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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Among the options listed, cheese is the food that is contraindicated with MAOI use. Cheese is high in tyramine, and consuming it while taking MAOIs can lead to a potentially life-threatening hypertensive crisis.
An MAOI (Monoamine Oxidase Inhibitor) is a type of medication used to treat depression, anxiety, and other psychiatric disorders. When taking MAOIs, it is important to avoid certain foods that contain high levels of tyramine, as it can lead to a dangerous increase in blood pressure known as a hypertensive crisis.
Choice B reason:
Potatoes: Potatoes are not contraindicated with MAOI use. They do not contain significant levels of tyramine.
Choice C reason:
Grapefruit: Grapefruit is not contraindicated with MAOI use. However, it can interact with certain medications, so it's always a good idea to check with the healthcare provider or pharmacist about specific medication interactions.
Choice D reason:
D. Eggs: Eggs are not contraindicated with MAOI use. Like potatoes, they do not contain significant levels of tyramine.
Correct Answer is A
Explanation
A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.
B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.
C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.
D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.
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