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 B
Explanation
Choice A: A barking cough is not a finding that indicates that the treatment has been effective, but rather a symptom of acute laryngotracheobronchitis, which is also known as croup. Croup is a condition that causes inflammation and narrowing of the upper airway and produces a characteristic barking or seal-like cough. A barking cough may persist for several days after the onset of croup and does not reflect the severity of the airway obstruction.
Choice B: Decreased stridor is a finding that indicates that the treatment has been effective, as stridor is a sign of airway obstruction caused by acute laryngotracheobronchitis. Stridor is a high-pitched, noisy breathing sound that occurs when the air passes through the narrowed airway. Stridor may be inspiratory, expiratory, or biphasic,
depending on the level of obstruction. Decreased stridor means that the airway is less obstructed and the child can breathe more easily.
Choice C: Improved hydration is not a finding that indicates that the treatment has been effective, but rather a goal of treatment for acute laryngotracheobronchitis. Dehydration can worsen the symptoms and complications of croup by thickening the mucus and increasing the risk of infection. Improved hydration can help thin out the mucus and prevent dehydration. Hydration can be improved by encouraging oral fluids, administering intravenous fluids, or providing humidified air.
Choice D: Decreased temperature is not a finding that indicates that the treatment has been effective, but rather a possible outcome of treatment for acute laryngotracheobronchitis. Fever may or may not be present in croup, depending on the cause and severity of the condition. Fever can be caused by viral or bacterial infection, inflammation, or dehydration. Decreased temperature can indicate that the infection or inflammation is resolving or that the dehydration is corrected.
Correct Answer is D
Explanation
Choice A: Restraining the child's arms is not an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can cause injury to the child or the nurse. Restraining the child's arms can also increase the child's anxiety and agitation, which can worsen the seizure.
Choice B: Using a padded tongue blade is not an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can cause injury to the child's mouth, teeth, or tongue. Using a padded tongue blade can also increase the risk of choking or aspiration, which can compromise the child's airway.
Choice C: Attempting to stop the seizure is not an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can be ineffective or harmful. Attempting to stop the seizure can also interfere with the natural course of the seizure, which may be necessary for the brain to recover.
Choice D: Positioning the child laterally is an appropriate action for a nurse to take when caring for a child who is experiencing a seizure, as this can help maintain the child's airway and prevent aspiration. Positioning the child laterally means placing the child on their side with their head tilted slightly forward and their mouth open.
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