NCLEX-PN

Category - Health Promotion

The nurse is assessing the fontanels of a 4-week-old infant. Which of the following actions of the nurse is the most appropriate during the assessment?
  1. Position the infant in upright position
  2. Stimulate the infant to induce crying
  3. Place the infant in supine position
  4. Instruct the mother to stay outside the room during the assessment
Explanation
Answer: A - Placing the infant in an upright position allows the nurse to accurately assess the client’s fontanels. The examination should be done when the infant is quiet, as crying can cause the fontanels to bulge, resulting in inaccurate results. Placing the infant in supine position may also yield inaccurate results. The nurse should include the mother during assessment to promote mother and child bonding.
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