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 C
Explanation
ADHD primarily causes symptoms related to inattention, hyperactivity-impulsivity, or a combination of both.
With ADHD, someone may experience difficulties paying attention and staying organized.
Choice A is not correct because difficulty in acquiring reading skills is not a specific symptom of ADHD.
Choice B is not correct because difficulty using words in context is not a specific symptom of ADHD.
Choice D is not correct because difficulty performing self-grooming activities is not a specific symptom of ADHD.
Correct Answer is A
Explanation
This is a sign of uterine hyperstimulation, which can cause fetal distress and excessive bleeding12.
The nurse should report this finding to the provider and monitor the fetal heart rate and maternal vital signs.
Choice B.
Early decelerations in the FHR are incorrect, as this is a normal finding during the second stage of labor, indicating head compression.
Choice C.
Pelvic pressure with contractions is incorrect, as this is an expected finding during the second stage of labor, indicating that the baby is descending through the birth canal.
Choice D.
Bloody show from the vagina is incorrect, as this is also an expected finding during the second stage of labor, indicating cervical dilation and effacement13.
Therefore, choice A is the best answer.
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