A nurse is collecting data from a 6-month-old infant in the well child clinic.
Which of the following findings should the nurse expect?
Infant's birth weight is tripled.
Lateral incisors are present.
Posterior fontanel is closed.
Infant sits well without support.
The Correct Answer is C
Choice A rationale
The infant's birth weight typically doubles by 4-6 months and triples by 1 year of age. If an infant's weight has tripled at 6 months, it may indicate overnutrition or an underlying health condition.
Choice B rationale
Lateral incisors usually appear between 9 to 13 months. At 6 months, the central incisors are more likely to be emerging.
Choice C rationale
The posterior fontanel typically closes by 2 to 3 months of age. Therefore, by 6 months, it is expected to be closed.
Choice D rationale
Infants usually sit without support around 8 months. At 6 months, they may sit with support or briefly without support but not consistently.
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Correct Answer is D
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.
Correct Answer is B
Explanation
Choice A rationale
Learning to use creative energies relates to the initiative vs. guilt stage, aimed at preschool children, where they begin asserting power and control over their world through play and social interactions.
Choice B rationale
Defining a sense of self is a task during the identity vs. role confusion stage in adolescence. Adolescents work on discovering who they are by exploring beliefs, values, and goals to create a consistent and unique identity.
Choice C rationale
Building a sense of trust is a task during the trust vs. mistrust stage of infancy. Infants need reliable caregiving to develop trust in their environment and the people around them.
Choice D rationale
Learning to perform tasks independently occurs in the autonomy vs. shame and doubt stage, which is observed in toddlers. This stage is about children gaining confidence in their abilities to perform basic tasks on their own.