A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?

Choice A Reason:

Exhibits head lag when pulled to a sitting position is correct. At 5 months old, infants typically show improvement in head control, and head lag (where the infant's head falls back when pulled to a sitting position) should be diminishing. Persistent head lag might indicate potential developmental concerns or issues with muscle tone that warrant further evaluation by the healthcare provider.

Choice B Reason:

Unable to hold a bottle is incorrect. At 5 months old, some infants might not have developed the ability to hold a bottle independently yet. This skill can vary among infants and might not be a significant concern at this stage.

Choice C Reason:

Unable to roll from back to abdomen is incorrect. Rolling from back to abdomen might not be fully developed in all infants at 5 months old. It's a milestone that some infants achieve later within the 5 to 6-month range, so it might not be an immediate concern unless it persists significantly beyond that range.

Choice D Reason:

Absent grasp reflex is incorrect. By 5 months old, the typical infant's grasp reflex usually starts to diminish as voluntary grasping begins to develop. However, the absence of the grasp reflex might not be an immediate concern unless it's accompanied by other signs of developmental delay or regression.

Choice A Reason:

Administer aspirin for fever is incorrect. Aspirin is contraindicated in children with varicella due to the risk of Reye's syndrome. Reye's syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella.

Choice B Reason:

Initiate airborne precautions is correct.Varicella is transmitted via airborne droplets. Use airborne precautions (negative air-flow rooms) for patients with varicella. If negative air-flow rooms are not available, isolate patients in closed rooms with no contact with people without evidence of immunity

Choice C Reason:

Assess the oral cavity for Koplik spots is incorrect. Koplik spots are associated with measles, not varicella. Varicella typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.

Choice D Reason:

Varicella can cause fever and discomfort, and providing a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is more important to initiate airborne precautions.