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✅ Answer
The finding the nurse should notify the provider about is: Anterior fontanel closed
Rationale
• The anterior fontanel is expected to remain open until 12 to 18 months of age.
• Closure at 4 months is premature (craniosynostosis), which can restrict brain growth and development.
• Posterior fontanel closed is normal for a 4-month-old (it typically closes by 2 to 3 months).
• Rolling and playing with toes are expected milestones for a 4-month-old.
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Clearly See the Questions, Below Actual Copyrighted 2025 Exam, Confirmed and Verified)
Answer
The instruction the nurse should include is:
Give the toddler a sticker after each successful toileting attempt.
Rationale
This utilizes positive reinforcement (the sticker), which is the most effective training technique for
children, especially those with cognitive impairments. The immediate, tangible reward creates a clear
and concrete link between the desired behavior and the positive outcome, promoting faster learning.
Requiring 20 minutes on the toilet is too long and can lead to resistance and frustration.
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✅
Answer
Crackles heard in the lungs
Rationale
Crackles indicate pulmonary edema (fluid in the lungs), which is a classic, critical sign of fluid overload
(hypervolemia). The other options (weight loss, decreased skin turgor, decreased blood pressure) are signs of fluid volume
deficit (dehydration).
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Answer
The action by the AP the nurse should intervene on is:
Raises all four side-rails on the client's bed
Rationale
Raising all four side-rails is considered a restraint and is not a safe fall prevention method. It can actually increase the risk
of serious injury if the client attempts to climb over the rails, resulting in a higher, more dangerous fall. The other actions
are appropriate fall prevention strategies.