A nurse is collecting data from a 3-month-old infant.
Which of the following findings should the nurse report to the provider?
The infant is unable to roll from the back to the abdomen.
The infant is unable to use a pincer grasp to pick up objects.
The infant is unable to raise his head when in a prone position.
The infant is unable to sit without support.
The Correct Answer is C
By 3 months old, most babies can lift their heads and chest up from a belly-down position.
Choice A is not correct because it is normal for a 3-month-old infant to be unable to roll from back to abdomen.
Choice B is not correct because it is normal for a 3-month-old infant to be unable to use a pincer grasp to pick up objects.
Choice D is not correct because it is normal for a 3-month-old infant to be unable to sit without support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A positive urine hCG test is a priority assessment to assess for a possible pregnancy.
The human chorionic gonadotropin (hCG) hormone is produced by the placenta after implantation and can be detected in the urine of pregnant women.
A urine hCG test is a common method used to confirm pregnancy.
Choice B is not an answer because changes in uterine size and shape occur later in pregnancy and are not a priority assessment for early pregnancy detection.
Choice C is not an answer because a fetal heartbeat can usually be detected at around 6-7 weeks of pregnancy and is not a priority assessment for early pregnancy detection.
Choice D is not an answer because Chadwick’s sign, which refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow, occurs later in pregnancy and is not a priority assessment for early pregnancy detection.
Correct Answer is B
Explanation
The nurse should teach the patient to report promptly any edema of the face and hands.
Edema of the face and hands can be a sign of preeclampsia, a serious pregnancy complication that can lead to high blood pressure and damage to organs such as the liver and kidneys.
Preeclampsia can be dangerous for both the mother and the baby and requires prompt medical attention.
Choice A is not an answer because nasal congestion is a common symptom during pregnancy and is not considered a danger sign.
Choice C is not an answer because hemorrhoids are also a common symptom during pregnancy and are not considered a danger sign.
Choice D is not an answer because varicose veins are also a common symptom during pregnancy and are not considered a danger sign.
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