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 A
Explanation
Varicella (chickenpox) is highly contagious and can be spread through the air by coughing or sneezing.
Airborne precautions help prevent the spread of the disease to others.
Choice B is wrong because Koplik spots are a symptom of measles, not varicella.
Choice C is wrong because providing a warm blanket is not a specific intervention for a child with varicella.
Choice D is wrong because aspirin should not be given to children with varicella due to the risk of Reye’s syndrome.
Correct Answer is D
Explanation
The nurse should plan to administer the human papillomavirus (HPV) vaccine to the 12-year-old client.
The Centers for Disease Control and Prevention (CDC) recommends that children aged 11-12 years old receive two doses of the HPV vaccine separated by 6-12 months.
Choice A is wrong because Hepatitis A vaccine is typically given to children at age.
Choice B is wrong because Varicella vaccine is typically given to children at ages 12-15 months and 4-6 years.
Choice C is wrong because DTaP vaccine is typically given to children at ages 2, 4, and 6 months, and between ages 15-18 months and 4-6 years.
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