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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
“6 weeks after fertilization.” Teratogens can begin affecting the developing embryo as early as 10 to 14 days after conception 1.
During embryonic development, there are periods when the developing organ systems show more sensitivity to teratogens.
Choice A is incorrect because 18 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice C is incorrect because 12 weeks after fertilization is not the earliest stage of pregnancy when exposure to a teratogenic agent could occur.
Choice D is incorrect because this is not an incomplete question/stem.
Correct Answer is C
Explanation
This question is important because it helps the nurse assess the level of risk and determine the appropriate intervention.
It is important to take all threats, communications, and suggestions regarding suicide seriously.
Choice A is not correct because it focuses on past events rather than the current situation.
Choice B is not correct because it may come across as confrontational and may not be helpful in assessing the level of risk.
Choice D is not correct because it focuses on the reason for feeling depressed rather than assessing the level of risk and determining appropriate intervention.
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