The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?
The toddler's anterior fontanel is not fully closed.
The toddler gained 3 in in height since last year.
The toddler gained 4 lb in weight since last year.
The circumference of the child's head increased 1 in since last year.
The Correct Answer is A
A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.
B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.
C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.
D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.
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Related Questions
Correct Answer is D
Explanation
A. Controls impulsive feelings: Preschoolers are still developing their ability to control impulses. While they may begin to understand the concept of rules and consequences, complete control over impulsive feelings is not typically expected at this stage.
B. Expresses need for privacy: Preschoolers may begin to show a growing awareness of privacy but may not consistently express this need or fully understand its implications. This is more commonly seen in older children and adolescents.
C. Builds a collection of cards: Building a collection of cards is not a typical developmental task for preschoolers. While they may engage in collecting objects, the items they collect are often related to their interests and may vary widely.
D. Participates in imaginary play: Imaginary play is a significant aspect of preschoolers' development. They often engage in make-believe scenarios, role-playing, and using objects symbolically to represent other objects. This type of play fosters creativity, social skills, and cognitive development in preschool-aged children.
Correct Answer is C
Explanation
A. Carotid artery: The carotid artery is not typically used to assess heart rate in infants due to its location and difficulty in palpation.
B. Radial artery: The radial artery is not typically used to assess heart rate in infants, especially in non-cooperative or newborn infants.
C. Apex of the heart: Assessing the heart rate by auscultating the apex of the heart with a stethoscope is the most accurate method for infants.
D. Brachial artery: The brachial artery is not typically used to assess heart rate in infants. It is commonly used to measure blood pressure.
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