# 一名嬰兒因嘔吐及頭圍增加接受評估。護理師在如圖所示條件下重複囟門檢查。點擊支持真正囟門膨出且需緊急評估，而非短暫姿勢或哭泣相關飽滿的觀察結果。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=581186&lang=zh-tw  
> language: zh-TW  
> subject: Physiological Adaptation  
> category: PA

## 題目

一名嬰兒因嘔吐及頭圍增加接受評估。護理師在如圖所示條件下重複囟門檢查。點擊支持真正囟門膨出且需緊急評估，而非短暫姿勢或哭泣相關飽滿的觀察結果。

![](https://mymerci.kr/data/nclex/hotspot/regen_20260908_2350/HSR523.svg)

## 解析

D 在嬰兒安靜且直立時仍維持凸起，不同於哭泣時的短暫飽滿。

## 深入解析

快速解答
D。D 在嬰兒安靜且直立時仍維持凸起，不同於哭泣時的短暫飽滿。
為何這是最佳選擇
姿勢與行為可能暫時改變外觀。在安靜且頭部直立時持續膨出令人擔憂，尤其伴隨本案症狀。請安排緊急評估；僅憑圖示無法確立特定病因。
臨床情境
觀察結果為虛構教學資料。請應用所述情境；所選特徵本身不能取代完整的床邊評估。
記憶口訣
在嬰兒安靜且頭部直立時重新評估囟門飽滿度。
決策規則
在嬰兒安靜且頭部直立時重新評估囟門飽滿度。
為何其他區域不合適
A 顯示仰臥且哭泣時飽滿，可能為短暫現象。B 在直立且安靜時平坦。C 在睡眠時輕微凹陷，非凸起囟門。D 在排除短暫解釋的條件下持續存在。
**資料來源**
- 安靜且直立時消退的飽滿並非真正膨出；持續膨出需緊急評估。

## 重要概念

- **Persistent fontanelle fullness after position and behavior change** — 在嬰兒安靜且頭部直立時重新評估囟門飽滿度。
- **Comparison with context** — A 與 D 具有相同的凸起形狀，但檢查條件不同。

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