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 D
Explanation
The nurse should assist the client to shift position every 4 hours to prevent complications such as pressure ulcers and pneumonia.
Choice A is incorrect because the weights on the traction should be freely hanging and not touching any part of the bed.
Choice B is incorrect because isometric exercises may not be appropriate for a client with a femur fracture and should be prescribed by a healthcare provider.
Choice C is incorrect because administering pain medication before performing pin care may not be necessary and should be based on the client’s level of pain and the healthcare provider’s orders.
Correct Answer is C
Explanation
The MSAFP test measures the levels of alpha-fetoprotein (AFP) in the mother’s body.
AFP is a protein produced by the baby during pregnancy.
Too much AFP in the mother’s body may indicate that the baby is at risk of a neural tube defect, like spina bifida.
Choice A is incorrect because this test does not screen for gestational diabetes.
Choice B is incorrect because this test does not screen for fetal maturity.
Choice D is incorrect because this test does not screen for ABO incompatibility.
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