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","C","D"]
Explanation
Choice A reason:
Breast changes are considered a presumptive sign of pregnancy. This means they are subjective indications reported by the woman and may not be definitive evidence of pregnancy. During pregnancy, the woman's breasts may undergo various changes such as tenderness, enlargement, and darkening of the areolas. These changes are primarily due to hormonal fluctuations and increased blood flow to the breast tissue.
Choice B reason:
Ballottement is not a presumptive sign of pregnancy. Ballottement is a clinical maneuver performed by a healthcare provider to assess the mobility of the fetus in the amniotic fluid. It involves tapping on the cervix and feeling for a rebound from the floating fetus. While it is an indication of pregnancy, it is not considered a presumptive sign as it requires a trained professional to detect.
Choice C reason:
Urinary frequency is a presumptive sign of pregnancy. During pregnancy, the growing uterus can put pressure on the bladder, leading to increased urinary frequency. However, urinary frequency can also be caused by other factors such as urinary tract infections, so it is not a definitive sign of pregnancy.
Choice D reason:
Nausea, specifically morning sickness, is a presumptive sign of pregnancy. Many pregnant women experience nausea and vomiting, especially during the first trimester, due to hormonal changes. However, nausea can also be caused by various other conditions, making it a presumptive rather than a confirmatory sign of pregnancy.
Choice E:
A positive pregnancy test is a probable sign of pregnancy rather than a presumptive sign. Pregnancy tests detect the presence of human chorionic gonadotropin (hCG), a hormone produced during pregnancy. A positive test provides strong evidence of pregnancy, but it is not considered a presumptive sign as it is an objective finding rather than a subjective symptom reported by the woman.
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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