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.
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Related Questions
Correct Answer is B
Explanation
A. Toddlers thrive on routines and consistency, which provide them with security and predictability.
B. Toddlers are in a stage of development where they assert their independence and autonomy by saying "no" or "mine" to almost everything. This is a normal and healthy behavior that reflects their growing sense of self and identity. The nurse should explain to the guardian that this behavior is not meant to be defiant or disrespectful, but rather a way of exploring their environment and expressing their preferences.
C. Toddlers are typically emotionally labile, meaning they can experience rapid changes in mood and emotions.
D. Toddlers may display increased independence rather than increased dependency as they strive to assert their autonomy.
Correct Answer is B
Explanation
A. Rotavirus vaccination is typically given in infancy, usually starting at 2 months of age, so it would not be administered to a 5-year-old child who is already up-to-date with the immunization schedule.
B. Varicella (chickenpox) vaccine is routinely administered around 12-15 months of age with a booster dose typically given between 4-6 years of age. Therefore, a 5- year-old child would receive the booster dose if not already administered.
C. Haemophilus influenzae type b (Hib) vaccine is usually completed by 15 months of age, so it would not be administered to a 5-year-old child who is already up-to- date with the immunization schedule.
D. Hepatitis B vaccine is typically administered at birth, 1-2 months, and 6-18 months of age, so a 5-year-old child who is up-to-date with immunizations would have already received the series.
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