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
A. "Postpone burping the infant until after completing each feeding."Burping should not be postponed. Infants with a cleft palate may have more difficulty with feeding and may need to be burped more frequently to reduce the risk of aspiration and discomfort.
B. "Feed the infant 177.4 ml. (6 oz) of formula three times each day."The amount and frequency of feeding should be individualized based on the infant's needs and growth patterns. Typically, an infant with a cleft palate requires more frequent, smaller feedings, and the total volume needs to be adjusted according to their specific nutritional needs.
C. "Discontinue a feeding if the infant's eyes become watery."Watery eyes during feeding can be a sign of aspiration or feeding difficulties. If this occurs, it is important to stop the feeding and assess the situation, as it may indicate that the infant is not handling the feeding well and could be at risk for aspiration or other complications.
D. "Elevate the infant's head to a 10° angle during feedings."A 10° angle may be too shallow to effectively prevent aspiration. Typically, the head should be elevated to a greater degree, often 30-45°, to help facilitate safer feeding and reduce the risk of aspiration in infants with a cleft palate.
Correct Answer is A
Explanation
Choice A Reason:
Pad the side rails of the crib is correct. This intervention aims to ensure the infant's safety by preventing injury or entrapment in the crib. It's relevant to prevent accidental harm, especially if the infant is experiencing seizures or increased muscle tone due to meningitis.
Choice B Reason:
Keep the television on in the room to provide background noise is incorrect. Background noise might be distracting and uncomfortable for an infant with bacterial meningitis, especially if they're experiencing sensitivity to light and sound due to their condition. A quiet, calm environment is generally more conducive to their recovery.
Choice C Reason:
Place the infant in a semiprivate room is incorrect. Providing a quieter environment with fewer disturbances can be beneficial for an infant with bacterial meningitis. This measure promotes rest and minimizes exposure to potential infections from other patients.
Choice D Reason:
Provide frequent range of motion to the neck and shoulders is incorrect. In cases of bacterial meningitis, particularly when inflammation occurs in the meninges (the protective membranes covering the brain and spinal cord), excessive movement or manipulation of the head and neck might be painful and could exacerbate symptoms.
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