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 ["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.
Correct Answer is C
Explanation
A. Prolonged crying: Prolonged crying can occur after an immunization, especially in infants, but it is generally not an immediate cause for concern unless accompanied by other symptoms such as difficulty breathing or skin changes.
B. Temperature 37.7° C (99.9° F): A mild fever is a common side effect after immunizations and is usually not a cause for immediate concern. A temperature of 37.7°C (99.9°F) is within a normal range and typically resolves on its own.
C. Hives on the child's neck: Hives (urticaria) can indicate an allergic reaction, which could potentially be a serious response to the immunization. An allergic reaction requires immediate attention and intervention, as it may progress to more severe symptoms such as difficulty breathing or anaphylaxis.
D. Redness at the injection site: Redness at the injection site is a common and expected reaction following an immunization. It is generally not a cause for concern unless it is accompanied by severe swelling, pain, or other signs of infection.
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