A nurse is assessing an 8-month-old infant for cerebral palsy.
Which of the following findings is a manifestation of the condition?
Tracks an object with eyes.
Sits with pillow props.
Uses a pincer grasp to pick up a toy.
Smiles when a parent appears.
The Correct Answer is B
A cerebral palsy is a group of disorders that affect movement and muscle tone or posture.
It’s caused by damage that occurs to the immature, developing brain, most often before birth.
Signs and symptoms appear during infancy or preschool years.
In general, cerebral palsy causes impaired movement associated with exaggerated reflexes, floppiness or spasticity of the limbs and trunk, unusual posture, involuntary movements, unsteady walking, or some combination of these.
An 8-month-old infant with cerebral palsy may have developmental delays and may require pillow props to sit up.
Choice A, Tracking an object with eyes, is a normal developmental milestone for
an infant.
Choice C, Uses a pincer grasp to pick up a toy, is also a normal developmental
milestone for an infant.
Choice D, Smiles when a parent appears, is also a normal developmental milestone for an infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Infants with spina bifida, including those with myelomeningocele, have an increased risk of rectal anomalies, so avoiding rectal temperatures is essential. The correct and safe method of temperature measurement for these infants is typically axillary.
B. Placing the infant in a side-lying positionis not recommended for a child with myelomeningocele. The preferred position isprone to avoid pressure on the sac and reduce the risk of rupture and infection.
C.Maintains a dry dressing over the sac: While the sac should be kept covered, it is typically kept moist with sterile saline-soaked gauze to prevent it from drying out and to minimize the risk of infection.
D.Performs range of motion on the infant's hips: Range of motion exercises might be indicated later on, but initially, the focus is on protecting the sac and preventing complications.
Correct Answer is ["A","B","C","D","E"]
Explanation
The nurse should include all of these points in the teaching.
A. Avoiding bubble baths can help prevent irritation and infection.
B. Watching for manifestations of infection can help detect any worsening or recurrence of the infection.
C. Emptying the bladder completely with each void can help prevent urine from remaining in the bladder and causing infection.
D. Wiping the perineal area front to back can help prevent bacteria from
spreading to the urethra.
E. Wearing cotton underpants can help keep the area dry and reduce the risk of infection.
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