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?
No head lag when pulled to a sitting position
Doll's eye reflex intact
Presence of tears when crying
Positive Babinski reflex
The Correct Answer is B
A. No head lag when pulled to a sitting position is a normal finding at 4 months of age.
B. They should not have doll's eye reflex intact, which means that their eyes move in the opposite direction of their head when turned. This reflex normally disappears by 3 months of age and its persistence may indicate brain damage.
C. The presence of tears when crying is a normal finding at 4 months of age.
D. They should also have positive Babinski reflex, which means that their toes fan out when their sole is stroked. This reflex normally disappears by 12 months of age.
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Related Questions
Correct Answer is D
Explanation
A) Abrasions on the knees could result from normal childhood activities and may not indicate physical abuse.
B) Front deciduous teeth missing could be due to normal tooth loss.
C) Weight in the 45th percentile is within a normal range and does not necessarily indicate physical abuse.
D) Bruising around the wrists is concerning for physical abuse, especially in a pattern consistent with restraining or gripping.
Correct Answer is A
Explanation
A. This is the first step to control bleeding and prevent further blood loss.
B. Monitoring the distal pulse is important, but controlling bleeding takes precedence.
C. Vital signs can wait momentarily until the bleeding is under control.
D. Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority.
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