A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse not report to the provider?

The infant does not exhibit fear of strangers.

The infant does not roll over from his abdomen to his back.

The infant does not pick up objects from the floor with his fingers.

The infant does not sit on the floor unsupported.

Answer and Explanation

The Correct Answer is A

A. The infant does not exhibit fear of strangers.

The infant does not exhibit fear of strangers is not a finding that the nurse should report to the provider, as this is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.

B. The infant does not roll over from his abdomen to his back.

By 6 months of age, most infants can roll over in both directions— from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.

C. The infant does not pick up objects from the floor with his fingers.

By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.

D. The infant does not sit on the floor unsupported.

By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Reye syndrome causes fatty changes in the liver."

This statement is correct. Reye syndrome is characterized by acute non-inflammatory encephalopathy and fatty changes in the liver, which can lead to liver dysfunction and failure.

B. "Reye syndrome leads to venous thrombus formation."

This statement is incorrect. Reye syndrome primarily affects the brain and liver, leading to cerebral edema and liver dysfunction. It does not typically involve venous thrombus formation.

C. "Reye syndrome is associated with misuse of acetaminophen."

This statement is incorrect. While the exact cause of Reye syndrome is not fully understood, it is not associated with the misuse of acetaminophen. However, there is a well-established association between Reye syndrome and the use of aspirin (salicylates) during viral infections, particularly in children and adolescents.

D. "Reye syndrome is linked to decreased serum ammonia levels."

This statement is incorrect. Reye syndrome is associated with increased serum ammonia levels due to liver dysfunction and impaired ammonia metabolism. Elevated ammonia levels can contribute to the encephalopathy seen in Reye syndrome.

A. Have the child perform passive range-of-motion exercises. B. Administer aspirin as needed for pain. C. Place ice packs on the affected joints. D. Position the lower extremities below the level of the heart.

Correct Answer is C

Explanation

A. Have the child perform passive range-of-motion exercises: This is not recommended during acute hemarthrosis in hemophilia because it can further exacerbate bleeding and increase joint damage. Passive range-of-motion exercises should be avoided until bleeding has been adequately controlled.

B. Administer aspirin as needed for pain: Aspirin is not recommended for pain management in hemophilia due to its antiplatelet effects, which can further prolong bleeding. Instead, acetaminophen (Tylenol) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that do not affect clotting mechanisms may be used for pain relief.

C. Place ice packs on the affected joints: This is a recommended intervention. Ice packs can help reduce inflammation and swelling in the affected joints, providing pain relief and potentially slowing down bleeding. However, it's important to ensure that the ice pack is wrapped in a cloth or towel to prevent direct contact with the skin, which could cause tissue damage.

D. Position the lower extremities below the level of the heart: This is not recommended. Elevating the affected extremity above the level of the heart can help reduce swelling and minimize bleeding. Placing the lower extremities below the level of the heart could potentially increase bleeding.

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A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse not report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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