A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
Doll's eye reflex intact
No head lag when pulled to a sitting position
Positive Babinski reflex
Presence of tears when crying
The Correct Answer is A
A. The doll's eye reflex, or oculocephalic reflex, is a normal reflex in infants up to about 2 months of age. It involves the eyes moving in the opposite direction of head movement. By 4 months of age, this reflex
typically disappears as the infant’s voluntary eye movements become more developed. Therefore, if the
B. By 4 months of age, it is normal for an infant to show significant reduction in head lag when pulled to a sitting position. Ideally, the infant should be able to hold their head up with minimal lag.
C. The Babinski reflex is a normal reflex in infants, where the toes fan out when the sole of the foot is stroked. This reflex is expected to be positive in infants up to about 12-24 months of age. By 4 months, a positive Babinski reflex is still normal and does not indicate a problem.
D. Infants typically start producing tears around 2-3 months of age. By 4 months, the presence of tears when crying is a normal developmental milestone and indicates healthy lacrimal gland function. Therefore, this finding is normal and does not need to be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Amphotericin B is an antifungal medication used to treat serious fungal infections. Impetigo is a bacterial infection and would not be treated with this medication.
B. Impetigo is highly contagious and spread through direct contact. Contact isolation precautions are essential to prevent the spread of the infection to other patients.
C. Healthcare facilities may have internal protocols for reporting certain infections but impetigo is not typically a reportable disease to state health departments.
D. Lidocaine is a local anesthetic and is not indicated for the treatment of impetigo. Antibiotics are the appropriate treatment.
Correct Answer is B
Explanation
A. While witnessing the signature is part of the process, addressing the guardian's lack of understanding is more important at this point.
B. The provider who will perform the procedure is best equipped to explain the medical necessity of the cardiac catheterization to the guardian. They can address the guardian's concerns and ensure informed consent.
C. While the anesthesiologist is part of the care team, they may not be as knowledgeable about the specific reasons for the procedure as the performing provider.
D. Nurses should not provide medical diagnoses or explanations for procedures. This is the role of the healthcare provider.
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