A nurse is collecting data from a 4-month-old infant who has meningitis. Which of the following manifestations should the nurse expect?
Constipation
Depressed anterior fontanel
Presence of the rooting reflex
High-pitched cry
The Correct Answer is D
D. A high-pitched cry, often described as a "crying in pain" or "irritable cry," can be a characteristic sign of meningitis in infants. The cry may sound different from the infant's usual cry and may be associated with irritability, discomfort, or pain. It can be indicative of increased intracranial pressure and neurological irritation caused by the inflammation of the meninges.
A. Constipation is not typically associated with meningitis in infants. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord, which can cause symptoms such as fever, irritability, poor feeding, vomiting, and lethargy.
B. A depressed anterior fontanel (sunken soft spot on the baby's head) is not a typical manifestation of meningitis. Meningitis may cause signs of increased intracranial pressure, such as a bulging fontanel, rather than a depressed fontanel.
C. he presence of the rooting reflex is not specific to meningitis. The rooting reflex is a normal reflex present in infants, where they turn their head toward a stimulus (such as stroking the cheek or corner of the mouth) in search of nourishment (typically the breast or bottle).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Clubbing, characterized by bulbous enlargement of the fingertips and nail bed, is a result of chronic hypoxia in tetralogy of Fallot. In tetralogy of Fallot, there is a right-to-left shunting of blood due to the presence of a ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. This leads to reduced oxygenation of blood and chronic hypoxia, which can result in clubbing of the fingertips over time.
A This option is not the primary explanation for clubbing in tetralogy of Fallot. While decreased cardiac output may contribute to some manifestations of the condition, clubbing specifically results from chronic hypoxia rather than decreased cardiac output alone.
B Clubbing is not directly caused by a left-to-right shunting of blood. Instead, it is associated with chronic hypoxia, which can occur due to right-to-left shunting of blood in tetralogy of Fallot.
D Congestive heart failure may occur in individuals with tetralogy of Fallot but it is not the primary cause of clubbing. Clubbing in tetralogy of Fallot is primarily attributed to chronic hypoxia rather than heart failure alone.
Correct Answer is D
Explanation
D The forward bending test, also known as the Adam's forward bend test, is commonly used to screen for idiopathic scoliosis. During this test, the child is instructed to bend forward from the waist with their arms hanging downward and palms touching or overlapping. This position allows the nurse to observe the child's back for asymmetry, rib humps, or other signs of spinal curvature characteristic of scoliosis.
A This position may be used for certain examinations, such as assessing the spine's curvature but it is not typically the position used for screening for idiopathic scoliosis.
B This instruction involves cervical spine movement and is not relevant to screening for idiopathic scoliosis. It may be part of a different examination, such as assessing cervical spine range of motion or neurological function, but it does not aid in detecting scoliosis.
C Turning to the side and remaining relaxed may not provide adequate visualization of the spine's curvature, which is essential for scoliosis screening. Additionally, this position does not allow for proper assessment of the spine's alignment.
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