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A nurse palpates an infant’s anterior fontanelle and notes that it feels soft and flat when lying down, but slightly elevated when sitting up or crying.

What should be included in documentation?



Correct Answer: A

Normal finding.

The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.

It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.

This is not a sign of any problem and should be documented as a normal finding.

Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.

Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.

Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.




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