A nurse is assessing a 5-month-old infant.
Which of the following findings should the nurse report to the provider?
Unable to hold a bottle.
Unable to roll from back to abdomen.
Absent grasp reflex.
Exhibits head lag when pulled to a sitting position.
The Correct Answer is C
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should first check the pH of the gastric secretions to confirm the placement of the NG tube before administering the enteral feeding.
Choice A is wrong because flushing the tube with water should be done after confirming the placement of the NG tube.
Choice B is wrong because attaching the feeding bag tubing to the end of the NG tube should be done after confirming the placement of the NG tube.
Choice D is wrong because setting the administration rate on the feeding pump should be done after confirming the placement of the NG tube.
Correct Answer is D
Explanation
Sudden infant death syndrome (SIDS) death has a devastating effect on parents.
There is no known cause, so parents experience guilt about what they might have done or not done to contribute to the death.
Acknowledging the family members’ feelings of guilt can help provide support to the family.
Choice A is wrong because there are no specific instructions discouraging the parents from allowing siblings to view the body.
Choice B is wrong because avoiding discussing details of the attempt to revive the infant may not necessarily provide support to the family.
Choice C is wrong because while providing a follow-up phone call 1 week following the infant’s death may be helpful, it is not the only action that should be taken by the nurse.
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