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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. The newborn does not respond to a loud noise.

A newborn should exhibit a startle response to a loud noise, indicating intact auditory sensory skills. Failure to respond to a loud noise may suggest a deficit in auditory perception.

B. The newborn's eyes focus on near objects.

Focusing on near objects is a normal visual response in newborns as they adjust to their visual environment. This behavior does not necessarily indicate a sensory deficit.

C. The newborn becomes more alert with stroking when drowsy.

Being more alert with stimulation when drowsy is a normal response and does not necessarily indicate a sensory deficit.

D. The newborn's eyes wander and occasionally are crossed.

In newborns, wandering eyes and occasional crossing are common as their visual system continues to develop. This behavior is not necessarily indicative of a sensory deficit at this stage.

A. Describing the tongue extrusion reflex B. Explaining how to prepare table meats C. Advising about increased caloric needs D. Discussing the type of sippy cup to use

Correct Answer is C

Explanation

A. Describing the tongue extrusion reflex: The tongue extrusion reflex is typically present in

infants up to around 4 to 6 months of age and diminishes as they begin to eat solid foods. At 7 months, this reflex is likely no longer prominent.

B. Explaining how to prepare table meats: While introducing solid foods is important around 6 months of age, meats are often introduced later in infancy due to their texture and potential

allergenicity. At 7 months, infants may still be primarily consuming pureed or mashed foods.

C. Advising about increased caloric needs: At 7 months, infants are transitioning to a more varied diet that includes solid foods alongside breast milk or formula. Guidance on meeting their

increasing nutritional needs is crucial at this stage.

D. Discussing the type of sippy cup to usE. Sippy cups are typically introduced closer to the end of the first year or during the transition to weaning from the bottle. While it's important to

discuss appropriate feeding utensils, addressing increased caloric needs is a more immediate concern for a 7-month-old infant.

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The nurse is performing a physical assessment of a 3-year-old girl. What finding would be a concern for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a new mother about the development of sensory skills in her newborn. What would alert the mother to a sensory deficit in her child?

Correct Answer is A

Explanation

The nurse is caring for a 7-month-old girl during a well-child visit. Which intervention is most appropriate for this child?

Correct Answer is C

Explanation

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