Which of the following steps is correct when measuring head circumference in an infant?
Measure from the back of the head to the forehead.
Place the measuring tape above the eyebrows and around the widest part of the head.
Measure from the chin to the top of the head.
Wrap the measuring tape tightly around the neck.
The Correct Answer is B
Choice A rationale
Measuring from the back of the head to the forehead is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice B rationale
Placing the measuring tape above the eyebrows and around the widest part of the head is the correct method for measuring head circumference in an infant. The tape should be wrapped around the head at the points just above the eyebrows, above the ears, and around the back where the head slopes up prominently from the neck.
Choice C rationale
Measuring from the chin to the top of the head is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice D rationale
Wrapping the measuring tape tightly around the neck is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Soft and flat fontanels are normal in healthy infants. In hydrocephalus, increased intracranial pressure causes bulging fontanels due to excess cerebrospinal fluid accumulation.
Choice B rationale: Proteinuria is a renal finding and not associated with hydrocephalus. Hydrocephalus affects the central nervous system, not kidney filtration or protein excretion.
Choice C rationale: Dilated scalp veins occur due to elevated intracranial pressure from cerebrospinal fluid buildup. Venous distension is a visible sign in infants with hydrocephalus.
Choice D rationale: Hypertension is not a typical sign of hydrocephalus in infants. The condition primarily presents with neurological and cranial changes, not systemic blood pressure elevation.
Correct Answer is A
Explanation
Choice A rationale
A bulging fontanel is a common sign of increased intracranial pressure (ICP) in infants. The fontanels, or soft spots on an infant’s head, allow for brain growth. When there is increased pressure, as in conditions that cause increased ICP, it can cause the fontanels to bulge outwards.
Choice B rationale
Insomnia is not typically associated with increased ICP in infants. Changes in consciousness, such as irritability or lethargy, may be seen, but these are not the same as insomnia.
Choice C rationale
A low-pitched cry is not typically associated with increased ICP in infants. Changes in cry might occur, but they are not specific to increased ICP4.
Choice D rationale
A positive Babinski reflex is normal in infants up to about 12 months of age. It is not specifically associated with increased ICP4.
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