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 B
Explanation
Choice A Reason:
"Your child should ride the bicycle against the flow of traffic." This instruction is incorrect. Children should ride their bicycles in the same direction as traffic flow to reduce the risk of accidents.
Choice B Reason:
This instruction emphasizes the importance of caution and attentiveness when crossing intersections. Walking the bicycle through intersections allows the child to have better control and visibility, reducing the risk of collisions with vehicles or other cyclists. It also ensures that the child can more easily observe traffic signals and pedestrian crossings. Therefore, this instruction promotes safe behavior and helps prevent accidents at intersection
Choice C Reason:
"Your child should keep the bicycle at least 3 feet from the curb while riding in the street." This instruction is a good guideline. Riding a safe distance away from the curb can help avoid obstacles and allow for better maneuverability.eeping the bicycle at least 3 feet from the curb allows for a buffer zone between the cyclist and potential hazards such as parked cars, debris, or opening car doors. It also increases visibility to motorists and reduces the risk of being struck by a car or encountering obstacles in the roadway.
Choice D Reason:
"Your child's feet should be 3 to 6 inches off the ground when seated on the bicycle." This instruction isn't related to safety but rather to the appropriate seat height adjustment for comfortable and efficient cycling. It might not be a primary safety concern.
Both instructions contribute to overall bicycle safety, but if we have to choose one, "B.Your child should walk the bicycle through intersections" is crucial because intersections are high-risk areas where accidents are more likely to occur. Therefore, this instruction should be prioritized in the teaching.
Correct Answer is C
Explanation
Choice AReason:
Chocolate milk is incorrect. Similar to ice cream, chocolate milk is dairy-based and may have a thicker consistency, potentially causing discomfort or irritation to the throat.
Choice B Reason:
Sugar-free cherry gelatin-Avoid red, purple, or brown liquids, which simulate the appearance of blood if the child vomits.
Choice CReason:
Although the flavor might be a bit acidic, lime-flavored ice pops are generally clear or light in color and less likely to obscure bleeding. They are also soothing and can help with hydration
Choice D Reason:
Vanilla ice cream is incorrect. While ice cream might seem soothing, it's dairy-based and can coat the throat, potentially causing discomfort or mucus production, which may not be ideal for the healing process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.