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
A nurse would recommend having crackers handy at the bedside and eating a few before getting out of bed to alleviate nausea in the early morning for a pregnant woman 1.
Eating foods that don’t aggravate your stomach, such as crackers, can help limit morning sickness.
Choice A is not an answer because eating three well-balanced meals per day and limiting snacks may not help alleviate nausea.
Eating small meals can help limit morning sickness.
Choice C is not an answer because drinking a full glass of fluid at the beginning of each meal may not help alleviate nausea.
Drinking throughout the day, not just when you are thirsty, can help limit morning sickness.
Choice D is not an answer because eating a bland diet and avoiding concentrated sweets may not help alleviate nausea.
Eating foods that don’t aggravate your stomach can help limit morning sickness.
Correct Answer is D
Explanation
B. This is the vaccine for hepatitis B, a viral infection that can cause liver damage and cancer.
The CDC recommends that all newborns receive the first dose of this vaccine within 24 hours of birth, followed by two more doses at 1 to 2 months and 6 to 18 months of age.
Choice A.
MMR is incorrect, as this is the vaccine for measles, mumps, and rubella, which is not given at birth but at 12 to 15 months and 4 to 6 years of age.
Choice B.
Varicella is incorrect, as this is the vaccine for chickenpox, which is also not given at birth but at 12 to 15 months and 4 to 6 years of age.
Choice C.
DTaP is incorrect, as this is the vaccine for diphtheria, tetanus, and pertussis (whooping cough), which is not given at birth but at 2, 4, 6, and 15 to 18 months and 4 to 6 years of age.
Therefore, choice D is the best answer to this question.
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