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 D
Explanation
Choice A rationale
Discouraging the client from ambulating is not necessary. In fact, early ambulation is often encouraged to promote circulation and prevent complications, depending on the fracture
type and treatment plan.
Choice B rationale
Keeping the client's leg in a dependent position is not recommended as it can increase swelling and pain. Elevating the leg is typically advised to reduce swelling.
Choice C rationale
Using a hair dryer on a hot setting to dry the cast is unsafe as it can cause burns and damage the cast. It's better to allow the cast to dry naturally and follow the healthcare provider's
instructions.
Choice D rationale
Performing a neurovascular check of the lower extremities is crucial to assess circulation, sensation, and movement. This helps in identifying any complications such as impaired
blood flow or nerve damage.