NCLEX Exam Practice Question of the Week - 12/14/11

Elsevier NCLEX Exam Review

Question: A nurse is assessing a 3-week-old infant admitted to the pediatric unit with hydrocephalus. What finding identifies a complication requiring immediate attention?


1. Tense anterior fontanel
2. Uncoordinated eye/muscle movement
3. Larger head circumference than chest circumference
4. Inability to support the head while in the prone position

Answer:1

Rationale:  A tense or bulging fontanel is indicative of increased intracranial pressure, which is caused by the fluid accumulation associated with hydrocephalus. Conjugate gaze does not occur until 3 to 4 months of age when eye muscles are mature. The head is the largest part of the body at this age; the head circumference should be about 1 inch larger than the chest. An infant cannot support the head before 1 to 1½ months of age.
Clinical Area: Child Health Nursing
Client Needs: Physiological Adaptation
Cognitive Level: Application
Nursing Process: Assessment

This week’s NCLEX exam practice question came from:

Nugent: Mosby's Review Questions for the NCLEX-RN Exam, 7th Edition, Chapter 5, pg 425, question 316

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