A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night.
Which finding is most significant in planning care for this family?
The mother states the baby is irritable during feedings.
The mother is a single parent and lives with her parents.
The infant's formula has been changed twice.
The diaper area shows severe skin breakdown.
The Correct Answer is D
The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The startle reflex, also known as the Moro reflex, is a normal reflex in infants that is present at birth and usually disappears by 3-4 months of age. The reflex is elicited by a sudden loud noise or change in position, and the infant will extend their arms and legs, then bring them back in towards their body.
If a 6-month-old infant is still demonstrating the startle reflex, it may indicate a developmental delay or neurological issue and requires further evaluation by the nurse or healthcare provider.
The other responses are all normal developmental milestones for a 6-month-old infant. By 6 months of age, most infants will have doubled their birth weight, enjoy playing games like peek-a-boo, and have developed the ability to turn their head to locate sounds.

Correct Answer is C
Explanation
To determine a possible urinary tract infection in a preschool-aged child who presents with flank pain, dysuria, and low-grade fever, the nurse should gather additional information from the parent about new onset bedwetting. New onset bedwetting can be a sign of a urinary tract infection in children. The other options (A, B, and D) are not directly related to determining a possible urinary tract infection in this situation.

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