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A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find?
- A. Anterior fontanel closes by age 6 to 10 months.
- B. Binocularity is well established by age 8 months.
- C. Birth weight doubles by age 5 months and triples by age 1 year.
- D. Maternal iron stores persist during the first 12 months of life.
Correct Answer: C
Rationale: The statement that best describes the infant's physical development that a nurse should expect to find is that birth weight doubles by age 5 months and triples by age 1 year. This characteristic growth pattern is typical in the first year of life. Infants usually regain their birth weight by around 2 weeks of age, double it by about 5 months, and triple it by 1 year. This steady growth reflects the healthy development of the infant and is an important marker of overall well-being and nutrition. It is a key aspect that healthcare providers, including nurses, monitor closely to ensure the infant is thriving.
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The majority of lumbar disc herniations occur at the level of:
- A. L1 - L2
- B. L4-L5
- C. L3-L4
- D. S1-S2
Correct Answer: B
Rationale: The majority of lumbar disc herniations occur at the level of L4-L5. This is because the L4-L5 disc segment bears the highest amount of stress and load in the lumbar spine due to its location and mechanics. The intervertebral disc between the fourth (L4) and fifth (L5) lumbar vertebrae is subject to repetitive movements and mechanical stress, making it more susceptible to herniation compared to other levels in the lumbar spine. Additionally, the anatomy of the L4-L5 disc makes it more prone to degeneration and herniation, leading to a higher prevalence of herniated discs at this level.
A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.)
- A. Weight loss
- B. Facial edema
- C. Cloudy smoky brown-colored urine
- D. Fatigue
Correct Answer: B
Rationale: Facial edema is a common clinical manifestation of nephrotic syndrome due to fluid retention and protein loss in the urine.
The nurse is examining an infant for hip placement and has abducted her flexed legs. The nurse should next:
- A. Rotate the hips.
- B. Extend the legs.
- C. Listen for a "click."
- D. Palpate the hips for a mass.
Correct Answer: C
Rationale: In this scenario, the nurse is performing Ortolani's maneuver, which is used to assess for developmental dysplasia of the hip (DDH) in infants. After abducting the infant's flexed legs, the nurse should then listen for a "click" that may indicate hip instability. A positive click suggests subluxation of the femoral head and may indicate the presence of DDH. It is important for the nurse to recognize this finding promptly and report it to the healthcare provider for further evaluation and management. Rotation of the hips, extending the legs, and palpating for a mass are not the appropriate next steps in this specific assessment for DDH.
Children with severe traumatic brain injury (TBI) may experience autonomic dysfunction characterized by all the following EXCEPT
- A. elevated temperature
- B. elevated heart rate
- C. elevated respiratory rate
- D. lowered blood pressure
Correct Answer: D
Rationale: Autonomic dysfunction in TBI typically involves elevated temperature, heart rate, and respiratory rate due to dysregulation of the autonomic nervous system. Lowered blood pressure is less common and may indicate hypovolemia or other conditions rather than autonomic dysfunction.
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client's fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: Maintaining strict records of intake and output is the best way to assess the client's fluid balance in this situation. Severe burns can lead to fluid loss, which can result in dehydration and other complications. By carefully monitoring the amount of fluid the client is taking in (intake) and the amount of fluid being eliminated from the body (output), healthcare providers can assess the client's fluid balance and make necessary adjustments to prevent dehydration or fluid overload. This approach provides accurate and specific information to guide fluid management and ensure optimal recovery for the client with burns. Monitoring skin turgor, daily weight, and checking for edema are also important measures, but maintaining strict records of intake and output is the most direct and effective method for assessing fluid balance in a client with burns.