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 D
Explanation
The nurse should first offer the mother's private time with the newborn to allow her to grieve and say goodbye.
This can be an important part of the healing process for the mother.
Choice A is not an answer because contacting clergy is not the first action the nurse should take.
Choice B is not an answer because transferring the client to another unit is not the first action the nurse should take.
Choice C is not an answer because administering medication is not the first action the nurse should take.
Correct Answer is C
Explanation
The correct answer ischoice C.
Choice A rationale:
A lead level of 10 mcg/dL is above the CDC’s reference value of 3.5 mcg/dL and would require more immediate follow-up and intervention, not just rescreening in one year.
Choice B rationale:
A lead level of 18 mcg/dL is significantly elevated and would necessitate immediate medical intervention and frequent monitoring, rather than waiting a year for rescreening.
Choice C rationale:
A lead level of 4 mcg/dL is slightly above the CDC’s reference value of 3.5 mcg/dL.While it is concerning, it may be appropriate to rescreen in one year if no other risk factors are present.
Choice D rationale:
A lead level of 44 mcg/dL is dangerously high and requires urgent medical treatment and frequent follow-up, not just rescreening in one year.
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