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 A
Explanation
Choice A Reason:
Bradycardia is correct. This is because bradycardia, or a slower than normal heart rate, can indeed be an indicator of digoxin toxicity. Digoxin is a medication that affects the heart's rhythm, and toxicity can lead to an excessively slow heart rate among other symptoms.
Choice B Reason:
Jaundice is incorrect. Jaundice, characterized by yellowing of the skin and eyes due to elevated bilirubin levels, is not commonly associated with digoxin toxicity. It's more indicative of liver-related issues rather than digoxin toxicity.
Choice C Reason:
Diaphoresis is incorrect. Diaphoresis, or excessive sweating, is not typically a primary symptom of digoxin toxicity. While various medications or medical conditions can cause diaphoresis, it's not a common indicator of digoxin toxicity.
Choice D Reason:
Polyuria is incorrect. Polyuria, excessive urination, is not a typical symptom of digoxin toxicity. It's not a direct effect of the medication on the body's systems.
Correct Answer is B
Explanation
Choice A Reason:
Hyperactive reflexes are incorrect. Gasoline inhalation tends to affect the central nervous system and might result in CNS depression rather than hyperactivity, so hyperactive reflexes are less likely.
Choice B Reason:
Ataxia is correct.
Ataxia, which refers to a lack of muscle coordination or unsteady movements, can be an expected finding in individuals who have inhaled gasoline fumes. Gasoline inhalation can affect the nervous system, leading to symptoms like ataxia, dizziness, confusion, and unsteady gait.
Choice C Reason:
Hypothermia is incorrect. Gasoline inhalation is not typically associated with hypothermia. Inhaling gasoline vapors might cause respiratory irritation or CNS effects but not hypothermia.
Choice D Reason:
Pinpoint pupils is incorrect. Pinpoint pupils are more commonly associated with opioid use or certain medications affecting the nervous system. Gasoline inhalation is not typically associated with this pupil reaction.
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