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 D
Explanation
In teaching parents of a preschool-age child with heart failure, the nurse should include the following information:
Choice A Reason:
Withhold digoxin if the child's pulse is greater than 100/min. While monitoring the pulse rate is important in children taking digoxin, a pulse rate greater than 100/min alone may not always indicate the need to withhold digoxin. The decision to withhold digoxin should be based on healthcare provider instructions and specific parameters provided for the child's case.
Choice B Reason:
Increase the child's oxygen flow rate until the child no longer has cyanosis. Adjusting oxygen flow rates should be done under the guidance of healthcare providers and based on prescribed protocols. Cyanosis is a serious sign indicating decreased oxygenation and should be addressed promptly by seeking medical attention rather than attempting to adjust oxygen flow rates at home.
Choice C Reason:
Weigh the child once each month. Monitoring the child's weight is important in heart failure management to track fluid retention, but weighing the child once a month may not provide sufficient monitoring. The healthcare provider might recommend more frequent weight checks to monitor fluid status accurately.
Choice D Reason:
Provide for periods of rest. Children with heart failure often have limited cardiac reserve and can easily become fatigued. Allowing the child periods of rest is essential to conserve energy and prevent excessive fatigue or exhaustion.
Correct Answer is A
Explanation
Choice A Reason:
Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action assesses the strength and symmetry of the trapezius muscles.
Choice B Reason:
Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.
Choice C Reason:
Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.
Choice D Reason:
Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.
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