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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer at mealtimes: While iron supplements can be given with meals to reduce gastrointestinal upset, they are typically better absorbed on an empty stomach. Therefore, giving them at mealtimes may not optimize absorption.
B. Administer at bedtimE. Administering iron supplements at bedtime is not typically recommended unless specifically instructed by a healthcare provider.
C. Give with a 240 mL (8 oz) glass of milk: Milk can decrease the absorption of iron due to its calcium content, so giving iron supplements with milk is not recommended.
D. Give with orange juicE. Vitamin C enhances iron absorption, so giving iron supplements with orange juice is a common practice to improve absorption.
Correct Answer is B
Explanation
A. Has a fear of strangers: Fear of strangers typically emerges around 6 to 9 months of age as part of normal social development. While it indicates cognitive and emotional growth, it does not necessarily warrant further evaluation unless it is excessive or accompanied by other concerning behaviors.
B. Uses a unidextrous grasp: By 7 months, infants typically develop a more refined pincer grasp, where they can pick up small objects using the thumb and forefinger (bidextrous grasp). A unidextrous grasp (using only one hand) may suggest a delay in fine motor development and could warrant further evaluation by a healthcare provider.
C. Babbles one-syllable sounds: Babbling is a typical milestone in language development for
infants around 6 to 9 months of age. One-syllable babbling is expected at this stage and does not necessarily indicate a need for further evaluation.
D. Shows preferences towards foods: Developing food preferences is part of normal feeding behavior for infants. While it is important to ensure a balanced diet, showing preferences towards certain foods is not typically a cause for concern at this age.
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