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 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 WBC count of 10,000/mm is within the normal range, indicating a normal white blood cell count. There is no cause for concern, and the nurse does not need to report this result to the provider.
Choice B reason:
The Hgb level of 6.8 g/dL is significantly below the normal range, which indicates severe anemia. Menorrhagia, or heavy menstrual bleeding, could be a potential cause of this low hemoglobin level. Anemia can lead to various complications, including fatigue, weakness, and decreased oxygen delivery to tissues. This result requires immediate attention, and the nurse should promptly report it to the healthcare provider for further evaluation and management.
Choice C reason:
The Creatinine level of 0.8 mg/dL is within the normal range. Creatinine is a marker of kidney function, and a normal value suggests that the kidneys are functioning adequately. Since the result is normal, the nurse does not need to report this to the provider.
Choice D reason:
The Potassium level of 3.5 mEq/L is within the normal range, indicating a normal potassium level. There is no immediate concern with this result, and the nurse does not need to report it to the provider.
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