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
Choice A Reason:
Inserting an IV is not typically required for this specific test. The test involves applying a substance (pilocarpine) to the skin to stimulate sweat production in a localized area for sweat collection.
Choice B Reason:
Measuring protein in the urine over a 24-hour period is unrelated to the pilocarpine iontophoresis test for cystic fibrosis. Protein measurement in urine over a 24-hour period is a different diagnostic test used for various conditions, but not for cystic fibrosis diagnosis.
Choice C Reason:
Fasting for 8 hours prior to the test is not necessary for the pilocarpine iontophoresis test. There's no requirement for fasting before this particular test.
Choice D Reason:
"The test will measure the amount of chloride in your baby's sweat." Is correct. Pilocarpine iontophoresis testing is a diagnostic test used to measure the concentration of chloride in a person's sweat. Elevated chloride levels in sweat are a hallmark of cystic fibrosis, so this test helps in the diagnosis of the condition.
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.
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