As the nurse conducts an assessment on a newborn infant, what finding will the nurse anticipate?
Closed fontanels
Lanugo
Fine motor control
Six to eight teeth
The Correct Answer is B
Choice A reason: This is not a finding that the nurse will anticipate. Closed fontanels are the absence of soft spots on the skull where the bones have not yet fused together. They are abnormal and unexpected in newborn infants, as they indicate a premature closure of the skull bones, which can affect the brain development and growth. The nurse should assess the presence, size, shape, and tension of the fontanels, and report any abnormalities to the physician.
Choice B reason: This is the best answer. Lanugo is a fine, soft hair that covers the body of the fetus in the womb. It helps to keep the fetus warm and hold the vernix caseosa on the skin. Lanugo is normal and expected in newborn infants, especially those born before 40 weeks of gestation. The nurse should observe the amount and distribution of lanugo, and expect it to be shed within the first few weeks of life.
Choice C reason: This is not a finding that the nurse will anticipate. Fine motor control is the ability to coordinate the movements of the small muscles of the hands and fingers. It is not well developed in newborn infants, as they have not yet acquired the skills and coordination to manipulate objects or perform complex tasks. The nurse should assess the grasp reflex and the spontaneous movements of the hands and fingers, and expect them to improve over time.
Choice D reason: This is not a finding that the nurse will anticipate. Six to eight teeth are the number of teeth that usually erupt in infants between 6 and 12 months of age. They are not present in newborn infants, as they have not yet developed the teeth buds or the ability to chew solid foods. The nurse should inspect the gums and the oral cavity, and educate the parents on the oral hygiene and feeding practices for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a concerning finding for the nurse. Absence of tears when the infant cries is normal and expected in the first few months of life. The tear ducts and glands are not fully developed yet, and the infant does not produce enough tears to moisten the eyes or overflow the eyelids. The nurse should monitor the infant's hydration and eye health, but should not be alarmed by the absence of tears.
Choice B reason: This is not a concerning finding for the nurse. Presence of vernix caseosa at delivery is normal and expected in newborns, especially those born before 40 weeks of gestation. Vernix caseosa is a white, cheesy substance that covers the skin of the fetus in the womb. It protects the skin from the amniotic fluid and helps with temperature regulation and infection prevention. The nurse should gently wipe off the excess vernix caseosa, but should not try to remove it completely.
Choice C reason: This is not a concerning finding for the nurse. Presence of anterior and posterior fontanels is normal and expected in infants. Fontanels are soft spots on the skull where the bones have not yet fused together. They allow the skull to be flexible and accommodate the growing brain. The nurse should palpate the fontanels gently and assess their size, shape, and tension, but should not be worried by their presence.
Choice D reason: This is the concerning finding for the nurse. Absence of the rooting reflex is abnormal and unexpected in infants. The rooting reflex is an involuntary movement or response that the infant makes when the cheek or mouth is touched. The infant turns the head and opens the mouth, seeking the source of stimulation. The rooting reflex is essential for breastfeeding and feeding in general. The nurse should assess the infant's neurological status and consult with the physician if the rooting reflex is absent.
Correct Answer is B
Explanation
Choice A reason: This is not the main purpose of educating the client. The client may or may not teach others about their medications, but that is not the nurse's responsibility.
Choice B reason: This is the best answer. Educating the client helps them understand their health status, treatment options, and self-care needs. This empowers them to make informed decisions that affect their health and well-being.
Choice C reason: This is not a valid reason for educating the client. The client may still need the nurse's assistance even after receiving education. The nurse's role is to support the client, not to make them independent.
Choice D reason: This is not a good reason for educating the client. The client should not advise others on their medical conditions, as this may lead to misinformation or harm. The client should refer others to qualified health professionals for advice.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today