A nurse is collecting data from a 3-month-old infant. Which of the following is an expected developmental finding?
Rolls from back to side
Able to hold a rattle
Holds arms out to be picked up
Displays fear toward strangers
The Correct Answer is B
A. Rolling from back to side typically occurs around 4 to 5 months of age.
B. At 3 months, an infant is expected to be able to hold a rattle.
C. Holding arms out to be picked up usually develops around 7 to 9 months of age.
D. Fear toward strangers, known as stranger anxiety, typically begins around 6 to 8 months of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
Correct Answer is A
Explanation
A. Checking the color and temperature of the toes helps assess for adequate circulation and potential complications like compartment syndrome.
B. Applying cushioning to the cast edges is important for comfort but is not the immediate priority.
C. Using a fan can help the cast dry faster but is not the priority action.
D. Repositioning the toddler is important to prevent pressure sores, but ensuring proper circulation takes precedence.
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