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 and does not require notification of the provider.
B. The Doll's eye reflex (also known as oculocephalic reflex) should be absent by 4 months of age. Its persistence could indicate neurological abnormalities and warrants further evaluation by the provider.
C. Presence of tears when crying is a normal physiological response and does not require notification of the provider.
D. Positive Babinski reflex is normal in infants under 2 years old and typically disappears by 12 to 24 months of age. It does not require immediate notification of the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Options 1:
A. Keeping the child NPO is crucial to prevent further ingestion or aspiration of the battery, which could lead to serious complications.
B. Teaching the child's parents the importance of inspecting the child's play area is important for future prevention but is not the immediate priority in this acute situation.
C. Obtaining an informed consent is not the priority in this scenario. It should be done after keeping the child NPO.
Options 2:
A. Encouraging parents to inspect toys for easily removable parts is important for prevention but is not the immediate priority when dealing with a child who has already ingested a foreign object.
B. Preparing the child for flexible endoscopy is the second action to visualize and safely remove the battery from the esophagus.
C. Waiting for return of the gag reflex without taking immediate action could delay potentially life-saving interventions.
Correct Answer is B
Explanation
A. Increased capillary refill is not typically associated with hypoglycemia but may indicate poor peripheral circulation.
B. Shakiness is a common manifestation of hypoglycemia due to the release of epinephrine in response to low blood sugar levels.
C. Thirst is more commonly associated with hyperglycemia (high blood sugar levels) rather than hypoglycemia.
D. Decreased appetite may occur in hypoglycemia, but it is not as specific a symptom as shakiness.
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