2024 PN NCLEX Questions Nursing Practice Question
During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?
Correct Answer: A
Rationale: Measuring head circumference equal to chest circumference in an infant is typically within normal limits, especially around 6 months of age, indicating that growth is proceeding appropriately. Documenting these measurements in the health care record is essential for tracking growth trends over time.
Option B is misleading; it suggests abnormal growth patterns without evidence. Option C is unnecessary since equal measurements do not indicate a need for further imaging. Option D incorrectly assumes the presence of hydrocephalus, which cannot be concluded from this measurement alone. Proper documentation is the most appropriate action in this scenario.