A nurse is collecting data from a 9-month-old infant.

Which of the following findings requires a nursing intervention?

Positive Moro reflex.

Negative Doll's eye reflex.

Positive Babinski reflex.

Negative Crawl reflex.

Answer and Explanation

The Correct Answer is A

The correct answer is a. Positive Moro reflex.

Choice A reason:

Positive Moro reflex: This reflex should disappear by 6 months of age. Its presence at 9 months indicates potential neurological issues.

Choice B reason:

Negative Doll’s eye reflex: This reflex, indicating brainstem function, should be positive in infants. A negative result suggests severe brainstem dysfunction

Choice C reason:

Positive Babinski reflex: This reflex is normal up to 2 years of age. It indicates normal neurological development in infants.

Choice D reason:

Negative Crawl reflex: Crawling typically develops between 6-10 months. A negative crawl reflex at 9 months could indicate developmental delays

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Correct Answer is D

Explanation

Checking the baby’s skin three times each day can help the mother monitor for any skin irritation or breakdown caused by the harness.
This can help prevent complications and ensure that the harness is being used safely and effectively.

Choice A is not the best answer because the mother should not adjust the harness straps on her own.
This should be done by a healthcare provider to ensure that the harness is properly fitted.
Choice B is not the best answer because the diaper should be placed under the harness, not over it.
Choice C is not the best answer because massaging lotion on the skin around the harness clasps may not be necessary and could potentially cause skin irritation.

A. After another child takes a toy, the child cries and stomps his feet. B. A child playing in the kitchen area pretends to pour a glass of milk and repeats this over and over. C. While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack. D. A child flips the light switch off and on until the caregiver asks her to stop and join the other children in play.

Correct Answer is C

Explanation

A child with autism spectrum disorder may have problems with social communication and interaction, including ignoring a caregiver who offers them a snack.
Choice A is incorrect because crying and stomping feet after another child takes a toy is normal behavior for a 2- or 3-year-old child.
Choice B is incorrect because repeating an action over and over is not necessarily indicative of autism spectrum disorder.
Choice D is incorrect because flipping a light switch off and on until asked to stop and join other children in playing is not necessarily indicative of autism spectrum disorder.

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A nurse is collecting data from a 9-month-old infant. Which of the following findings requires a nursing intervention?

Nursing Test Bank

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A nurse is collecting data from a 9-month-old infant.

Which of the following findings requires a nursing intervention?