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 A Reason:
Check oxygen saturation every 4 hr.: While monitoring oxygen saturation is important, in acute epiglottitis, continuous monitoring of oxygen saturation is necessary due to the potential for rapid airway compromise. Intermittent checks every 4 hours may not provide timely information about deteriorating respiratory status.
Choice B Reason:
Obtain a throat culture: While obtaining a throat culture can help identify the causative organism, the priority in acute epiglottitis is securing the airway and stabilizing the child's condition. Attempting a throat culture could provoke agitation or worsen the obstruction due to irritation of the swollen epiglottis.
Choice C Reason:
Initiate droplet isolation precautions: This is an important action because acute epiglottitis is often caused by bacteria, such as Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae, which can spread via respiratory droplets. Isolation precautions help prevent the transmission of the infection to others and protect healthcare workers.
Choice D Reason:
Assist the child into the supine position: In acute epiglottitis, positioning the child supine (lying flat on the back) can worsen the airway obstruction. Keeping the child calm and in a comfortable position that allows easier breathing is important. Sitting the child upright or in a position of comfort that facilitates breathing and minimizes airway obstruction is preferred.
Correct Answer is C
Explanation
Choice A Reason:
A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL. A blood glucose level of 200 mg/dL in a child with diabetes may require management but is not an immediate life-threatening situation.
Choice B Reason:
A toddler who has nephrotic syndrome and facial edema. Facial edema in a child with nephrotic syndrome requires assessment and potential intervention but might not present an immediate threat to life compared to an airway obstruction.
Choice C Reason:
A preschool-age child who has a muffled voice and no spontaneous cough. The combination of muffled voice and the absence of spontaneous cough can be indicative of an upper airway obstruction, which can be life-threatening. This requires immediate assessment and intervention to ensure the child's airway is clear and that breathing is not compromised.
Choice D Reason:
An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb). Weight loss in an adolescent with Crohn's disease is concerning but might not represent an immediate life-threatening situation compared to a potential airway obstruction.
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