A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?
Uses a pincer grasp
Has a fear of strangers
Shows preferences towards foods
Babbles one-syllable sounds
The Correct Answer is A
Choice A: Using a pincer grasp indicates a need for further evaluation, as it is a developmental milestone that is usually achieved by 9 to 10 months of age. A pincer grasp is the ability to pick up small objects using the thumb and index finger. A 7-month-old infant should be able to use a raking grasp, which is the ability to scoop up objects using all fingers.
Choice B: Having a fear of strangers does not indicate a need for further evaluation, as it is a normal and expected behavior for a 7-month-old infant. A fear of strangers is a sign of attachment and recognition of familiar and unfamiliar faces. A 7-month-old infant may cry, cling, or turn away from strangers.
Choice C: Showing preferences towards foods does not indicate a need for further evaluation, as it is a normal and expected behavior for a 7-month-old infant. Showing preferences towards foods is a sign of individuality and taste development. A 7-month-old infant may accept or reject certain foods based on their flavor, texture, or appearance.
Choice D: Babbling one-syllable sounds does not indicate a need for further evaluation, as it is a normal and expected behavior for a 7-month-old infant. Babbling one-syllable sounds is a sign of language and communication development. A 7-month-old infant may make sounds such as "ba", "da", "ga", or "ma".
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Oliguria is a condition of reduced urine output, which can indicate dehydration, kidney failure, or urinary tract obstruction. It is not associated with a CNS infection, which affects the brain and spinal cord.
Choice B: A negative Brudzinski sign is a normal finding that indicates no meningeal irritation. It is elicited by flexing the neck of a supine patient and observing no involuntary flexion of the hips and knees. A positive Brudzinski sign, on the other hand, is a sign of meningitis, which is a type of CNS infection.
Choice C: A bulging fontanel is an abnormal finding that indicates increased intracranial pressure, which can be caused by a CNS infection, such as meningitis or encephalitis. A fontanel is a soft spot on the skull of an infant that allows for brain growth and development.
Choice D: Jaundice is a condition of yellowing of the skin and eyes, which can indicate liver disease, hemolytic anemia, or neonatal hyperbilirubinemia. It is not associated with a CNS infection, which affects the brain and spinal cord.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because the radial artery is not an ideal site to assess the heart rate in an infant. The radial artery is located on the thumb side of the wrist, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a strong pulse, but it may be difficult to locate or feel in an infant who has a small or weak pulse.
Choice B reason: This choice is incorrect because the carotid artery is not an ideal site to assess the heart rate in an infant. The carotid artery is located on either side of the neck, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a cardiac arrest or shock, but it may be risky to use in an infant who has a fragile neck or airway.
Choice C reason: This choice is incorrect because the brachial artery is not an ideal site to assess the heart rate in an infant. The brachial artery is located on the inner side of the upper arm, and it can be palpated by placing two fingers over it. It may be used for infants or young children who have a blood pressure measurement, but it may be uncomfortable or inaccurate to use for a heart rate assessment.
Choice D reason: This choice is correct because the apex of the heart is an ideal site to assess the heart rate in an infant. The apex of the heart is located at the fifth intercostal space on the left midclavicular line, and it can be auscultated by placing a stethoscope over it. It may be used for infants or young children who have a regular and strong heartbeat, and it may provide the most accurate measurement of the heart rate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today