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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.

A. Positive Moro reflex. B. Negative Doll's eye reflex. C. Positive Babinski reflex. D. Negative Crawl reflex.

Correct Answer is A

Explanation

The correct answer is a. Positive Moro reflex.

Choice A reason:

Positive Moro reflex: This reflex should disappear by 6 months of age. Its presence at 9 months indicates potential neurological issues.

Choice B reason:

Negative Doll’s eye reflex: This reflex, indicating brainstem function, should be positive in infants. A negative result suggests severe brainstem dysfunction

Choice C reason:

Positive Babinski reflex: This reflex is normal up to 2 years of age. It indicates normal neurological development in infants.

Choice D reason:

Negative Crawl reflex: Crawling typically develops between 6-10 months. A negative crawl reflex at 9 months could indicate developmental delays

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A nurse is collecting data from a 3-month-old infant. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?

Correct Answer is C

Explanation

A nurse is collecting data from a 9-month-old infant. Which of the following findings requires a nursing intervention?

Correct Answer is A

Explanation

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. This behavior is developmentally appropriate at which of the following ages?

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A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

An infant suffered from a fracture of the humerus and requires traction that uses pins, wires, and tongs. What type of traction is this?

A nurse is reinforcing teaching with a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSAFP) determination. Which of the following information should the nurse include?

A nurse is collecting data from a client who has skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

A nurse is collecting data from a 3-month-old infant.

Which of the following findings should the nurse report to the provider?