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 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.
Correct Answer is D
Explanation
The Ortolani test is a screening test that would help rule out a hip problem related to babies who are breech.
It is used to check for developmental dysplasia of the hip (DDH).
Choice A is not an answer because bracing is a treatment for DDH, not a screening test.
Choice B is not an answer because genu valgum is a condition where the knees angle in and touch each other when the legs are straightened, and it is not a screening test for DDH.
Choice C is not an answer because the Adams test is used to screen for scoliosis, not DDH.
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