You perform your primary assessment and question Mrs. H. with a translator. Which of these
findings are abnormal and need to be reported? Select all that apply and state rationale.
a. Anterior fontanel palpable and tense
b. Pupils equal and +3
c. Temperature 96.8 ° F (36 ° C) rectally
d. Heart rate: 85 beats/min
e. Positive Babinski reflex
f. High-pitched cry
g. Refusal of PO intake per mother
a, c, f, g
The anterior fontanel should be soft and flat. A tense or bulging fontanel can indicate increased
intracranial pressure (ICP). The posterior fontanel might be palpable until 2 months of age. A rectal
temperature of 36 ° C (96.8 ° F) is hypothermic and abnormal. The pupil assessment and pulse of 85
are within normal limits. A positive Babinski reflex is normal until 12 to 18 months. Irritability, high-
pitched crying, and refusal of feeding are abnormal.
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