A new mother is concerned because the anterior fontanelle swells ...

[2125004343]

A new mother is concerned because the anterior fontanelle swells when the newborn cries. What normal findings should the nurse include when teaching the new mother about this concern? Select all that apply.
 
  1. The fontanelles might bulge.
  2. The fontanelles might be depressed.
  3. The fontanelles can swell with crying.
  4. The fontanelles can pulsate with the heartbeat.
  5. The fontanelles can swell when stool is passed.

Question 2

The nurse is assessing a newborn's musculoskeletal status. How should the nurse assess for clubfoot?
 
  1. Stimulate the sole of the foot
  2. Adduct the foot and listen for a click
  3. Extend the foot and observe for pain
  4. Move the foot to midline and determine resistance

[SamMuagrove]

Answer to Question 1

3, 4, 5
Explanation:
1. Bulging fontanelles signify increased intracranial pressure.
2. Depressed fontanelles indicate dehydration.
3. Newborn fontanelles can swell when the newborn cries.
4. Newborn fontanelles can pulsate with the heartbeat.
5. Newborn fontanelles can swell when the newborn passes a stool.

Answer to Question 2

4
Explanation:
1. Stimulating the sole of the foot will elicit the plantar grasp reflex, and is not an appropriate assessment for clubfoot.
2. Adducting the foot and listening for a click is not an assessment that is done.
3. Extending the foot and observing for pain will not determine or rule out clubfoot.
4. Clubfoot is suspected when the foot will not turn to a midline position or align readily.