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 A

Explanation

This statement shows empathy and support for the client.
It also encourages the client to engage in self-care activities and promotes independence.
Choice B is not appropriate because it is a threat and does not show empathy or support for the client.
Choice C is not appropriate because it encourages the client to remain passive and does not promote independence.
Choice D is not appropriate because it is confrontational and does not show empathy or support for the client.

A. Ensure the scale is balanced prior to use B. Place a disposable covering on the scale C. Use a stadiometer to measure the infant D. Weigh the infant in a diaper

Correct Answer is ["A","B","D","E"]

Explanation

E. The nurse should ensure the scale is balanced prior to use [A], place a disposable covering on the scale [B], weigh the infant in a diaper [D], and measure the infant from the crown of the head to the heels of the feet [E].
Choice C is incorrect because a stadiometer is used to measure standing height and is not appropriate for measuring the length of an infant who cannot stand.

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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?