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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The nurse should provide the client with a carbonated beverage as a nonpharmacologic intervention to reduce pain from intestinal gas. Carbonated beverages, like soda or sparkling water, can help alleviate gas by promoting burping, which releases trapped gas from the digestive system. The effervescence of the carbonated drink can help relieve the discomfort caused by accumulated gas, offering relief to the client.
Choice B reason:
Encouraging the client to lie on their right side is not an effective nonpharmacologic intervention for reducing pain from intestinal gas. Although positioning can sometimes aid in relieving discomfort, lying on the right side does not specifically target the reduction of gas. Therefore, it is not the most appropriate choice in this scenario.
Choice C reason:
Encouraging the client to ambulate is a beneficial nonpharmacologic intervention for various post-operative conditions. However, when it comes to reducing pain from intestinal gas, it may not be as effective as other options. While movement can aid in gas passage through the digestive system, it might not be the most immediate or direct solution for alleviating the client's discomfort.
Choice D reason:
Providing the client with straws for beverages does not directly address the issue of intestinal gas. It is an unrelated intervention and may not provide any significant relief for the client's discomfort.
Correct Answer is B
Explanation
Choice A reason:
The client stating, "I should add 500 calories per day to my diet,” is not an accurate understanding of breastfeeding. While it is true that breastfeeding mothers require additional calories to support lactation, the specific amount of calories needed varies depending on individual factors and should be discussed with a healthcare professional. Simply adding 500 calories per day may not be appropriate for every woman and could lead to excessive weight gain.
Choice B reason:
This choice indicates an understanding of proper breast hygiene during breastfeeding. Using antibacterial soap and warm water to wash the breasts helps to prevent infection and maintain good breast health, reducing the risk of complications for both the mother and the baby.
Choice C reason:
The statement, "Breastfeeding is a reliable method of birth control,” is incorrect. While breastfeeding can provide some natural contraceptive effects, it is not a foolproof method of birth control. This concept is known as the lactational amenorrhea method (LAM), and specific criteria must be met for it to be considered a reliable form of contraception. Relying solely on breastfeeding as birth control can lead to an unintended pregnancy.
Choice D reason:
The statement, "If my nipples become cracked and red, I will apply hydrocortisone cream,” is not advisable. While hydrocortisone cream may provide temporary relief from irritation, it is not recommended for breastfeeding mothers. Ingestion of the cream by the baby can be harmful. Instead, the client should seek guidance from a healthcare professional to address and resolve any breastfeeding-related nipple issues.
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