Which assessment finding for a 4-month-old infant would require ...

[sjones]

Which assessment finding for a 4-month-old infant would require further action by the nurse?
 
  1. The posterior fontanel is open.
  2. The infant has good head control when held upright.
  3. The infant is able to roll only from abdomen to back.
  4. The anterior fontanel is open and soft.

Question 2

The postpartum client presents to the maternity clinic with complaints of urinary urgency and dysuria 3 days after hospital discharge. Which statement is most important for the nurse to make?
 
  1. Void into this sterile cup without touching the inside of the cup.
  2. Be sure to wipe from back to front after you have a bowel movement.
  3. Call the clinic if you develop nausea and vomiting or constipation.
  4. Decrease your fluid intake for a few days, but eat a lot of vegetables.

[janeli]

Answer to Question 1

1
Explanation:
1. The posterior fontanel closes between 2 and 3 months of age.
2. Good head control is expected at 4 months of age.
3. Rolling from abdomen to back is a skill the 4-month-old infant should be learning.
4. An open anterior fontanel, which is soft, is a normal finding at 4 months.

Answer to Question 2

1
Explanation:
1. A clean-catch urine sample will need to be obtained for urinalysis to determine if the client has developed a urinary tract infection.
2. Clients should be taught to wipe from front to back after bowel movements in order to prevent contamination of the urethra and bladder with normal bowel flora.
3. A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever and flank pain. Constipation is not associated with urinary tract infections.
4. Clients should increase their fluid intake but decrease their consumption of carbonated beverages. Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables do not help clear or prevent urinary tract infections.