A nurse is assessing a 15-month-old toddler during a well-child visit. Which of the following findings should the nurse report to the provider?

Displays a positive Babinski reflex

Absent Moro reflex

Refers to self by name

Points to a common object when asked

Answer and Explanation

The Correct Answer is A

Choice A reason: A positive Babinski reflex beyond 12 to 18 months is abnormal and indicates possible neurological dysfunction. At 15 months, the reflex should have disappeared as the nervous system matures. Persistence of this reflex suggests an upper motor neuron lesion or developmental delay, making it a reportable finding.

Choice B reason: The Moro reflex normally disappears by 4 months of age. Its absence at 15 months is expected and does not indicate abnormality.

Choice C reason: Referring to self by name is an appropriate developmental milestone for toddlers around 15 months. It reflects normal language and self-awareness development.

Choice D reason: Pointing to common objects when asked is a normal developmental milestone at this age, showing receptive language and cognitive development.

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Correct Answer is A

Explanation

Choice A reason: Applying a saturated abdominal dressing (with sterile normal saline) is correct. Moist dressings prevent the exposed abdominal organs from drying out and reduce the risk of tissue necrosis. This is the immediate priority intervention until surgical repair can be performed.

Choice B reason: Cleansing the site with hydrogen peroxide is inappropriate because it can damage exposed tissues and increase the risk of infection. Hydrogen peroxide is not used for internal organ exposure.

Choice C reason: Covering the site with dry, sterile gauze is incorrect because dry gauze can adhere to the viscera, causing tissue damage when removed. Moist dressings are required to protect the organs.

Choice D reason: Reinserting protruding viscera is unsafe and contraindicated. Attempting to push organs back into the abdominal cavity can cause trauma, infection, and further complications. The nurse should protect the viscera and notify the surgical team immediately.

A. Metoprolol B. Clopidogrel C. Metformin D. Digoxin

Correct Answer is B

Explanation

Choice A reason: Metoprolol is a beta-blocker used for hypertension and cardiac conditions. While it can affect heart rate and blood pressure, it does not pose a direct procedural risk during colonoscopy. Continuing metoprolol is generally safe and often recommended to avoid rebound hypertension.

Choice B reason: Clopidogrel is the correct answer because it is an antiplatelet medication that increases the risk of bleeding during invasive procedures such as colonoscopy, especially if polypectomy or biopsy is performed. Reporting this to the provider is a priority so that the risk can be managed, and the procedure can be delayed or adjusted if necessary.

Choice C reason: Metformin is used for diabetes management. While it can cause lactic acidosis in rare cases, especially with contrast studies, it does not pose an immediate risk during colonoscopy. It is not the priority medication to report.

Choice D reason: Digoxin is used for heart failure and arrhythmias. Although digoxin requires monitoring for toxicity, it does not directly increase procedural risk during colonoscopy. It is important but not the priority in this scenario.

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A nurse is assessing a 15-month-old toddler during a well-child visit. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

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