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:
Constipation is incorrect. While bowel obstruction might occur due to the nature of intussusception, it usually presents with a different pattern of symptoms such as sudden, severe abdominal pain, vomiting, and sometimes, passing of "currant jelly" stool, which is a mixture of blood and mucus.
Choice B Reason:
Sausage-shaped abdominal mass is correct. This type of abdominal mass might be palpable during the assessment. It's a classic sign associated with intussusception. The mass can often feel like a sausage-shaped or tubular lump in the abdomen.
Choice C Reason:
Board-like abdomen is incorrect. A board-like abdomen with rigidity is a sign more commonly associated with conditions like peritonitis, which involves inflammation or infection of the abdominal lining, but it's not typically seen in intussusception.
Choice D Reason:
Increased urinary output is incorrect. Intussusception doesn't directly cause increased urinary output. This finding is less likely to be associated with this specific condition.
Correct Answer is A
Explanation
A. "Check the pH of the gastric secretions."Checking the pH of the gastric secretions is crucial to confirm that the NG tube is correctly positioned in the stomach. This helps ensure that the tube is in the right place before administering the feeding, thereby reducing the risk of complications such as aspiration.
B. "Attach the feeding bag tubing to the end of the NG tube."Attaching the feeding bag tubing should be done after verifying the tube's placement and ensuring it is in the stomach. This step is important, but it follows confirmation of correct tube placement.
C. "Flush the tube with water."Flushing the tube with water is important to ensure patency and prepare the tube for feeding. However, this should only be done after confirming the tube's placement.
D. "Set the administration rate on the feeding pump."Setting the administration rate is necessary for administering the feeding but should be done after confirming tube placement and preparing the tube.
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