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
When people with bulimia nervosa frequently engage in self-induced vomiting, the gastric acids in their vomit can damage the tooth enamel.
This is called dental erosion and can create “bulimia teeth”.
Choice A, Food is rapidly ingested without proper mastication, is incorrect because it does not directly relate to tooth enamel deterioration.
Choice C, Poor dental and oral hygiene leads to dental caries, is incorrect because it refers to a different dental issue.
Choice D, Purging causes the depletion of dietary calcium, is incorrect because it does not directly relate to tooth enamel deterioration.
Correct Answer is A
Explanation
A positive urine hCG test is a priority assessment to assess for a possible pregnancy.
The human chorionic gonadotropin (hCG) hormone is produced by the placenta after implantation and can be detected in the urine of pregnant women.
A urine hCG test is a common method used to confirm pregnancy.
Choice B is not an answer because changes in uterine size and shape occur later in pregnancy and are not a priority assessment for early pregnancy detection.
Choice C is not an answer because a fetal heartbeat can usually be detected at around 6-7 weeks of pregnancy and is not a priority assessment for early pregnancy detection.
Choice D is not an answer because Chadwick’s sign, which refers to the bluish discoloration of the cervix, vagina, and vulva due to increased blood flow, occurs later in pregnancy and is not a priority assessment for early pregnancy detection.
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