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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While newborns may have incomplete lung expansion, this is not the primary reason for counting for a full minute.
B. The rate and rhythm of breaths in newborns are irregular, so counting for a full minute ensures an accurate assessment.
C. Activity can increase the respiratory rate, but this is true for all age groups and does not explain the need for a full minute count.
D. Newborns are abdominal breathers, but this does not affect the need for a full minute count.
Correct Answer is C
Explanation
A. Mouth breathing is common after a tonsillectomy due to throat pain and swelling but is not a specific sign of hemorrhage.
B. Reports of thirst can occur after surgery due to limited oral intake and mouth breathing but are not indicative of hemorrhage.
C. Frequent swallowing is a key sign of hemorrhage following a tonsillectomy, as the child may be swallowing blood that is dripping into the throat.
D. Reports of pain are expected after tonsillectomy but do not specifically indicate hemorrhage.
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