A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?
Exhibits head lag when pulled to a sitting position
Unable to hold a bottle
Unable to roll from back to abdomen
Absent grasp reflex
The Correct Answer is A
Choice A Reason:
Exhibits head lag when pulled to a sitting position is correct. At 5 months old, infants typically show improvement in head control, and head lag (where the infant's head falls back when pulled to a sitting position) should be diminishing. Persistent head lag might indicate potential developmental concerns or issues with muscle tone that warrant further evaluation by the healthcare provider.
Choice B Reason:
Unable to hold a bottle is incorrect. At 5 months old, some infants might not have developed the ability to hold a bottle independently yet. This skill can vary among infants and might not be a significant concern at this stage.
Choice C Reason:
Unable to roll from back to abdomen is incorrect. Rolling from back to abdomen might not be fully developed in all infants at 5 months old. It's a milestone that some infants achieve later within the 5 to 6-month range, so it might not be an immediate concern unless it persists significantly beyond that range.
Choice D Reason:
Absent grasp reflex is incorrect. By 5 months old, the typical infant's grasp reflex usually starts to diminish as voluntary grasping begins to develop. However, the absence of the grasp reflex might not be an immediate concern unless it's accompanied by other signs of developmental delay or regression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice AReason:
Exposure to secondhand smoke is incorrect. While exposure to secondhand smoke isn't healthy for anyone, it might not be a primary trigger for seizures in most cases. However, for some individuals, exposure to certain environmental toxins or irritants might exacerbate their condition, though this varies from person to person.
Choice BReason:
Decreased temperature is incorrect. While extreme temperatures (both hot and cold) can potentially trigger seizures in some individuals, decreased temperature alone might not be a common trigger compared to other factors.
Choice C Reason:
Lack of sleep is correct. Sleep deprivation can be a significant trigger for seizures in people with epilepsy or seizure disorders. Maintaining a regular sleep schedule and ensuring adequate sleep is an important aspect of managing seizures in these individuals.
Choice D Reason:
Prolonged headache is incorrect. Headaches can sometimes be a warning sign or an aura before a seizure for some individuals, but having a headache alone might not directly trigger a seizure for most people with a seizure disorder. However, there can be a relationship between headaches and certain types of seizures in specific cases.
Correct Answer is A
Explanation
Choice A Reason:
Relaxed facial expression is correct. Opioids, when effectively managing pain, can lead to a more relaxed facial expression in infants. It's a common indicator that the pain is being controlled and the infant is experiencing relief.
Choice B Reason:
Increased blood pressure is incorrect. Opioids usually cause a decrease in blood pressure rather than an increase. Elevated blood pressure wouldn't typically signify a therapeutic effect of opioids; it might indicate other factors such as stress, discomfort, or an adverse reaction.
Choice C Reason:
Limb withdrawal is incorrect. Limb withdrawal is a reflex action and might occur in response to a stimulus. It's not a direct indicator of pain relief; rather, it's a reflexive response to a sensation.
Choice D Reason:
Bradycardia is incorrect. Bradycardia, a slowed heart rate, can be a side effect of opioid medications. However, it's not an indicator of the therapeutic effect of pain relief. In fact, bradycardia might signal an adverse reaction or a dose that's too high for the infant.
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