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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Areola and papilla separate from the contour of the breast: This is a normal finding in breast development and indicates Tanner stage 4 or higher, which is typical for adolescent girls. It does not necessarily indicate a developmental delay.
B. Absence of first menstrual perioD. Menarche, the first menstrual period, typically occurs between the ages of 9 and 15 in girls. Absence of menarche by the age of 15 or within 3 years after the onset of breast development (thelarche) may indicate a developmental delay or underlying medical condition that should be evaluated by a healthcare provider.
C. Developed breast tissuE. Breast development, indicated by palpable breast tissue, is a normal part of female puberty and typically occurs before menarche. Developed breast tissue alone does not necessarily indicate a developmental delay.
D. Mature distribution and coarseness of pubic hair: Pubic hair development is also a part of female puberty and occurs before or around the time of menarche. While the distribution and coarseness of pubic hair can provide information about pubertal development, the absence of menarche is a more reliable indicator of a potential developmental delay.
Correct Answer is C
Explanation
A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." - This
statement is incorrect. There is no direct correlation between vaccines and SIDS. In fact, research has shown that vaccines are not a cause of SIDS.
B. "SIDS rates have been rising over the last 10 years." - This statement is misleading. SIDS rates have actually been decreasing over the past few decades due to increased awareness and preventive measures.
C. "Placing your child on her back when sleeping will decrease the risk of SIDS." - This statement is accurate. Placing infants on their backs to sleep is one of the most effective
strategies for reducing the risk of SIDS, according to recommendations from pediatric health organizations.
D. "Sleep apnea is the main cause of SIDS." - This statement is incorrect. While sleep apnea is a sleep-related breathing disorder, it is not the main cause of SIDS. SIDS is a complex phenomenon with multiple contributing factors, but sleep position plays a significant role in reducing its risk.
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