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

The infant exhibits a fear of strangers.

The infant understands the word "no".

The infant has an absent grasp reflex.

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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Correct Answer is D

Explanation

A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale.": Incorrect because the child should exhale forcefully and quickly into the device, not inhale or hold their breath.
B. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor.": Incorrect because a green zone reading indicates controlled asthma, and no immediate action is required.
C. "I will slowly exhale through the mouthpiece over a 10-second interval.": Incorrect because the exhalation should be rapid and forceful to measure peak flow effectively.
D. "I will record the highest reading of the three attempts." Recording the highest reading ensures accurate monitoring of airway status and helps the child track their progress over time.

A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. B. Place the child in prone position. C. Stabilize the thermometer at the distal end. D. Direct the tip of the thermometer toward the spine during insertion. E. None F. None

Correct Answer is B

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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