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A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

A.

The infant exhibits a fear of strangers.

B.

The infant understands the word "no".

C.

The infant has an absent grasp reflex.

D.

The infant rolls from their back to their abdomen.

Answer and Explanation

The Correct Answer is C

A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.


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Related Questions

Correct Answer is ["A","B"]

Explanation

A. Assess for changes in level of consciousness. Abdominal trauma can lead to internal bleeding, which might increase intracranial pressure if bleeding occurs in the brain. Monitoring for neurological changes is essential.
B. Administer factor VIII. Hemophilia A results from factor VIII deficiency, and replacing it prevents further bleeding.
C. Perform passive range of motion hourly. Movement may exacerbate bleeding into the joints or injured tissues. Rest is essential during acute bleeding episodes.
D. Administer factor IX. Factor IX is used for hemophilia B, not hemophilia A.
E. Apply a warming blanket over the child. Hypothermia management may be necessary in some trauma cases, but there is no indication it is needed here based on the scenario provided.

Correct Answer is C

Explanation

A. "My child will be awake for this procedure.": Incorrect because the child will be under sedation or anesthesia for safety and to prevent distress.
B. "I can take my child home as soon as the procedure is over.": Incorrect because the child must be monitored post-procedure for complications like airway swelling or sedation effects.
C. "The provider will remove the object during this procedure." A bronchoscopy allows visualization and removal of foreign objects from the airway, which is the purpose of the procedure.
D. "After this procedure, I have to wait 48 hours before I can give my child solid foods.": Incorrect because eating is typically resumed after the child recovers from sedation and demonstrates a safe swallow reflex.

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