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 B
Explanation
Choice A rationale
Capillary refill less than 2 seconds is a normal finding and suggests adequate perfusion. It is not indicative of a priority concern in this context.
Choice B rationale
Tingling in the right foot can indicate nerve damage or compromised circulation, which is critical to address in a patient with a fracture. This symptom could suggest complications like compartment syndrome, requiring immediate medical attention.
Choice C rationale
Respiratory rate of 24/min is slightly elevated but not directly related to the fracture's immediate complications. It requires monitoring but is not the priority.
Choice D rationale
A 2+ right pedal pulse indicates a normal pulse and adequate circulation in the foot. While important, it does not represent an immediate concern in this context.
Correct Answer is C
Explanation
Choice A rationale
A properly fastened harness and securely anchored car seat are essential for infant safety. This statement indicates correct practice and does not require further teaching.
Choice B rationale
Using an infant model car seat that is securely anchored is appropriate for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.
Choice C rationale
A front-facing car seat is inappropriate for a 6-month-old infant. Infants should ride in a rear-facing car seat until at least the age of 2 or until they reach the highest weight or height allowed by the car seat manufacturer. This statement indicates a need for further teaching.
Choice D rationale
A rear-facing car seat in the back passenger seat is the safest position for a 6-month-old infant. This statement is correct and does not indicate a need for further teaching.