A nurse is collecting data from a 4-year-old child during a well-child visit. Which of the following findings should the nurse expect?
Positive Babinski sign.
Birth height has doubled.
Birth weight has doubled.
Presence of permanent teeth.
The Correct Answer is C
Birth weight has doubled.
Choice A reason:
The nurse should not expect a positive Babinski sign in a 4-year-old child during a well-child visit. The Babinski sign is a reflex seen in infants up to about 1 year of age and disappears as the nervous system matures. Its presence in a 4-year-old would be abnormal and may indicate neurological issues.
Choice B reason:
The nurse should not expect birth height to double in a 4-year-old child during a well-child visit. While children do experience significant growth in their early years, it is unlikely that birth height will have doubled by the age of 4. Doubling of birth height would be an atypical finding.
Choice C reason:
The correct choice. The nurse should expect that the child's birth weight has doubled during a well-child visit. From birth to age 4, children typically experience substantial weight gain, and doubling of birth weight is a common milestone in healthy development.
Choice D reason:
The nurse should not expect the presence of permanent teeth in a 4-year-old child during a well-child visit. Permanent teeth typically begin to emerge around 6 years of age and continue to erupt over the following years. The appearance of permanent teeth at age 4 would be premature and unusual.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The nurse should not tell the client to lie flat on their back for the duration of the nonstress test. It is essential for pregnant clients to be in a semi-reclining or left lateral position during the test to avoid supine hypotension syndrome. This condition can occur when the weight of the uterus compresses the inferior vena cava, reducing blood flow to the heart and potentially compromising the baby's well-being.
Choice B reason:
The nurse should not instruct the client to lightly brush their palms across their nipples during the test. This statement is not related to the nonstress test procedure. The nonstress test involves monitoring the baby's heart rate in response to its movements, and nipple stimulation is not a standard part of the test.
Choice C reason:
The nurse should not advise the client not to eat or drink anything for 4 hours before the test. It is important for pregnant clients to have adequate nutrition and hydration, especially during the third trimester. Restricting food and drink for such a prolonged period could lead to dehydration and may not be necessary for the test.
Choice D reason:
This is the correct choice. During a nonstress test, the client is connected to a fetal heart rate monitor. They are asked to press a button whenever they feel the baby moving. This allows the healthcare provider to correlate the baby's movements with changes in the heart rate pattern, which helps assess the baby's well-being.
Correct Answer is C
Explanation
"I should call my provider if I notice thick white discharge in my underwear.”
Choice A reason:
The client stating, "I will need to have this device replaced every 3 years,” is incorrect. Subdermal progesterone contraception devices, such as Nexplanon, can typically last for up to 3 years, not needing replacement within that time frame. The rationale behind this is that these devices release a steady amount of progesterone to prevent pregnancy, and they are designed to be effective for the specified duration.
Choice B reason:
The statement, "This device will protect me from STIs,” in Choice B is incorrect. Subdermal progesterone contraception devices do not provide protection against sexually transmitted infections (STIs). Their primary function is to prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering the uterine lining, but they do not offer any defense against STIs. It is essential for the client to understand that barrier methods, such as condoms, are necessary for STI protection.
Choice C reason:
The correct answer, "I should call my provider if I notice thick white discharge in my underwear,” is an accurate statement. Thick white discharge could be indicative of a vaginal infection, such as yeast infection, which might require medical attention. It is crucial for the client to report any changes in vaginal discharge to their healthcare provider for proper evaluation and treatment.
Choice D reason:
The statement in Choice D, "I need to decrease the amount of milk I drink while I have this device,” is incorrect. There is no association between subdermal progesterone contraception devices and milk consumption. The device does not interfere with dairy intake or affect its metabolism. This information is unrelated to the proper use or management of the contraception device.
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