A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?
Can always track an object with eyes
Needs support with pillow props for sitting
Uses a pincer grasp to pick up a toy
Smiles when a parent appears
The Correct Answer is B
A. Can always track an object with eyes:
The ability to track an object with the eyes typically develops in infants around 2 to 3 months of age. This developmental milestone is not specific to cerebral palsy and is generally expected in healthy infants.
B. Needs support with pillow props for sitting
Explanation:
Cerebral palsy (CP) is a group of permanent movement disorders that appear in early childhood. It is caused by abnormal development or damage to the parts of the brain that control movement, balance, and posture. The symptoms of cerebral palsy can vary widely, but they are generally related to motor function and coordination.
The manifestation of needing support with pillow props for sitting is consistent with the motor impairments often seen in cerebral palsy. Children with cerebral palsy may have difficulties with muscle control and coordination, which can affect their ability to sit independently. The need for external support to maintain a sitting position is indicative of motor developmental delays or challenges associated with cerebral palsy.
C. Uses a pincer grasp to pick up a toy:
The pincer grasp, where a child uses the thumb and index finger to pick up small objects, usually develops around 9 to 12 months of age. This developmental milestone is not directly associated with cerebral palsy and is part of normal infant development.
D. Smiles when a parent appears:
Smiling in response to familiar faces, including parents, is a social and emotional developmental milestone that typically occurs around 2 to 3 months of age. While cerebral palsy can affect motor function, it does not directly impact an infant's ability to express emotions like smiling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply cool sterile soaks to the child's head.
Explanation: Applying cool sterile soaks to the child's head would not directly address periorbital edema. Nephrotic syndrome is a kidney disorder that results in proteinuria (loss of protein in urine), leading to fluid accumulation and edema. Cooling the head would not have a significant impact on reducing periorbital edema caused by nephrotic syndrome.
B. Apply warm compresses.
Explanation: Correct Choice. Applying warm compresses can help increase blood circulation and promote the reabsorption of excess fluid causing periorbital edema. Warmth can dilate blood vessels and improve the movement of fluids, potentially alleviating the edema.
C. Encourage the child to eat low protein foods.
Explanation: While dietary modifications might be part of managing nephrotic syndrome, specifically encouraging low protein foods may not directly address periorbital edema. The primary treatment for nephrotic syndrome involves medications to control proteinuria and manage fluid balance.
D. Elevate the head of the bed.
Explanation: Elevating the head of the bed is more commonly used to manage conditions like heart failure or obstructive sleep apnea. It might have some impact on overall fluid distribution, but it's not the most effective measure for reducing periorbital edema caused by nephrotic syndrome.
Correct Answer is C
Explanation
A. Assume you made a mistake and report out the same head circumference as before.
Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.
Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.
B. Take Vital Signs.
Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.
Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.
C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.
Correct Explanation: This is the best next step.
Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.
D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.
Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.
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