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 B
Explanation
A. Understands that death is permanent: Preschoolers generally do not understand the permanence of death. They may view death as temporary or reversible, as their cognitive development is still in the preoperational stage, where they are not fully able to grasp abstract concepts like the permanence of death.
B. Perceives death as a punishment: Preschoolers may view death as a punishment or something they caused, due to their egocentric thinking. They may think that their actions or behaviors (e.g., being "bad") have led to death, as they often see the world from a very self-centered perspective.
C. Has feelings of isolation: Feelings of isolation are more commonly seen in older children or adolescents who understand death better and may have social concerns. Preschoolers are more likely to be confused or fearful about death rather than experiencing isolation.
D. Worries about physical body changes: While preschoolers may be curious about their bodies, their primary focus is usually on the emotional and social aspects of death (e.g., fear of separation from loved ones), rather than worrying about physical body changes associated with dying.
Correct Answer is C
Explanation
A. Reinforce with the guardians to avoid discussing death with the child's siblings: Avoiding the discussion of death with the child's siblings can create confusion and anxiety. It's important to foster open communication and allow siblings to process their emotions about the situation in an age-appropriate manner.
B. Guide discussions with the child about death: Discussions about death should be handled delicately, considering the child’s age and understanding; this should be done in partnership with the family and healthcare providers.
C. Use a calm tone of voice when speaking with the child: A calm, reassuring tone of voice is essential when interacting with a child in palliative care. This helps provide comfort, reduces anxiety, and establishes a sense of safety for the child during a difficult time.
D. Encourage the guardians to seek a second opinion about their child's diagnosis:
Seeking a second opinion may be an option in some situations, but in the context of palliative care, the focus is typically on comfort and quality of life rather than pursuing further curative treatments.
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