During assessment of an infant, the nurse notes that when the infant cries, the fontanelles bulge slightly. What is the most appropriate action for the nurse at this time?

Question

Quizplus · Accepted Answer

The fontanelles frequently bulge when an infant is crying. The nurse will palpate the anterior and posterior fontanelles for fullness while the infant is in an upright position and calm. Microcephaly occurs when the head circumference is less than expected, which is not the finding here. An elevated fontanelle when the infant is calm may indicate overhydration or fluid volume excess. Transillumination is not needed in this case.

During Assessment of an Infant, the Nurse Notes That When