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
Paresthesia refers to an abnormal sensation of the skin, such as numbness, tingling, or burning.
When the nurse observes for diminished or absent sensation and numbness or tingling, they are monitoring for paresthesia.
Choice A is not correct because pain is not the symptom being monitored in this case.
Choice B is not correct because paralysis is not the symptom being monitored in this case.
Choice D is not correct because pallor refers to the paleness of the skin and is not the symptom being monitored in this case.
Correct Answer is B
Explanation
The nurse should instruct the parents to bring the infant’s favorite blanket to the hospital.
This can provide comfort and a sense of familiarity for the infant during their hospital stay.
Choice A is incorrect because reading a story about hospitalization to an 8- month-old infant may not be developmentally appropriate.
Choice C is incorrect because parents are usually allowed to stay with their infant during hospitalization.
Choice D is incorrect because manipulating the infant’s bedtime based on the hospital’s visiting hours is not necessary.
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