A nurse is collecting data from a 6-week-old infant. Which of the following findings should the nurse expect?
Absence of Babinski reflex
Absence of Moro reflex
Closure of the posterior fontanel
Closure of the anterior fontanel
The Correct Answer is C
A. Absence of Babinski reflex: The Babinski reflex (a fanning of the toes when the sole of the foot is stroked) is normal in infants and should be present until around 12 months of age. Its absence at 6 weeks would be atypical.
B. Absence of Moro reflex: The Moro reflex (a startle response) is typically present in newborns and may begin to disappear by 3-6 months of age. Its absence at 6 weeks would be concerning and could indicate neurological issues.
C. Closure of the posterior fontanel: The posterior fontanel typically closes by 6-8 weeks of age. This is a normal finding for a 6-week-old infant.
D. Closure of the anterior fontanel: The anterior fontanel typically closes between 12 and 18 months of age, not by 6 weeks. Therefore, closure of the anterior fontanel at 6 weeks would be unusual.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A school-age child who has Haemophilus influenzae type b disease: Haemophilus influenzae type b typically requires droplet precautions, not contact precautions, unless the infection is invasive like meningitis.
B. An adolescent who has pneumonia: Pneumonia caused by most pathogens does not require contact precautions unless there are specific indications such as a highly contagious organism or a superimposed infection that mandates isolation.
C. An infant who has respiratory syncytial virus (RSV): RSV is highly contagious and spreads through respiratory secretions. Contact precautions are necessary to prevent transmission, especially in healthcare settings.
D. A preschooler who has tuberculosis: TB is transmitted through the air via respiratory droplets, so airborne precautions (including a negative pressure room and an N95 respirator) are necessary to prevent transmission.
Correct Answer is ["A","B"]
Explanation
A. Oral rehydration solution: Oral rehydration solutions (ORS) are recommended to replace lost fluids and electrolytes during episodes of diarrhea. They help prevent dehydration, which is a common complication in infants with diarrhea.
B. Breast milk: Breast milk is the best option for a breastfed infant during an episode of diarrhea. It provides essential nutrients and hydration, as well as antibodies that can help protect against infections and improve recovery.
C. Chicken broth: Chicken broth is not recommended for infants under 6 months old due to its high sodium content and lack of essential nutrients for young infants. It could potentially cause electrolyte imbalances.
D. Clear soda: Clear soda should be avoided, as it contains high levels of sugar and can worsen dehydration. It does not provide the necessary electrolytes and fluids needed to rehydrate an infant.
E. Apple juice: Apple juice is not recommended for infants with diarrhea, as it can contribute to diarrhea due to its high sugar content, particularly fructose, which can draw water into the intestines and worsen dehydration.
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