A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention?

Negative Doll's eye reflex

Positive Moro reflex

Positive Babinski reflex

Negative Crawl reflex

Answer and Explanation

The Correct Answer is B

A. The negative Doll's eye reflex is normal in infants after a few weeks of life as the reflex should disappear by 2-3 months.
B. The Moro reflex typically disappears by 4-6 months of age. Persistence beyond this age may indicate neurological issues and requires further intervention.
C. The Babinski reflex is normal in infants up to 2 years of age.
D. The crawl reflex may not be consistently present at 9 months, but it is not as concerning as the persistence of the Moro reflex.

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Correct Answer is B

Explanation

A. Brisk capillary refill is not directly related to the effectiveness of tracheostomy suctioning.

B. Clear breath sounds indicate that secretions have been successfully removed from the airway, making the suctioning effective.

C. Increased respiratory rate could indicate distress or a need for further intervention.

D. Stable oxygen saturation is important but can be maintained by other means and does not solely indicate the effectiveness of suctioning.

A. Withhold fluids until the client demonstrates a gag reflex. B. Place a bedside humidifier at the head of the client's bed. C. Perform chest physiotherapy. D. Suction the nasopharynx as needed.

Correct Answer is A

Explanation

A. Withholding fluids until the client demonstrates a gag reflex ensures that the airway is protected and reduces the risk of aspiration.
B. While a humidifier can help keep the throat moist, it does not directly prevent aspiration.
C. Chest physiotherapy is not necessary for preventing aspiration in this scenario.
D. Suctioning the nasopharynx is useful if needed but is not the primary action to prevent aspiration.

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A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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