A term neonate is to be released from the clinic at two days of age. The nurse conducts a physical examination before discharge.
Nurse Bong Tayamen checks the neonate’s hands and palms. Which of the following findings requires further evaluation?
A. Many creases across the palm.
B. Absence of creases on the palm.
C. A single crease on the palm.
D. Two large creases across the palm.
Answer: A single crease on the palm.
The mother asks when the “soft spots” close? The nurse demonstrates that the neonate’s anterior fontanel will usually close by age…
A. 2 to 3 months.
B. 6 to 8 months.
C. 12 to 18 months.
D. 20 to 24 months
Answer: 12 to 18 months.
When doing the physical assessment, the nurse demonstrates to the mother that in a term neonate, sole creases are
A. Absent near the heels.
B. Evident under the heels only,
C. Spread over the entire foot.
D. Evident only towards the transverse arch.
Answer: Spread over the entire foot.
When evaluating the neonate’s eyes, the nurse records the following corneas of irregular size, contraction of the pupils in response to bright light, and the presence of red circles on the pupils. Which of these decisions requires further assessment?
A. The absence of tears.
B. Corneas of unequal size.
C. Constriction of the pupils.
D. The presence of red circles on the pupils.
Answer: Corneas of unequal size.
After explaining to the mother about the neonate’s positive Babinski reflex, the nurse discovers that the mother understands the directions when she says that a positive Babinski reflex indicates….
A. Immature muscle coordination.
B. Immature central nervous system.
C. Possible lower spinal cord defect.
D. Possible injury to nerves that innervate the feet.
Answer B. Immature central nervous system.
NCLEX NURSING QUESTION AND RATIONALE SUBJECT TO FUNDAMENTAL OF NURSING
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