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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is a variation of the side-lying position, which is recommended for pregnant women in the third trimester to improve blood flow to the uterus and the baby12.
Sleeping on the right side with a pillow under the hip can also help relieve pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Sleeping on the back can cause lightheadedness and dizziness because of this pressure, as well as increase the risk of stillbirth1.
Choice B.
Without a pillow is incorrect, as this can make sleeping on the side uncomfortable and cause back pain or leg cramps.
Choice C.
with a pillow under her shoulders is incorrect, as this can elevate the upper body and worsen heartburn, a common problem in pregnancy.
Choice D.
with a pillow under both hips is incorrect, as this can make sleeping on the back more likely, which is not advised for pregnant women in the third trimester1.
Therefore, choice A is the best answer.
Correct Answer is C
Explanation
A nurse caring for a toddler who had a cast applied 2 hours ago due to multiple fractures of the right hand should report immediately to the charge nurse if the fingers on the right hand have a capillary refill of 4 seconds.
This could indicate that there is a problem with circulation.
Choice A is not an answer because it is not unusual for a child to not attempt to move her right arm or fingers after having a cast applied.
Choice B is not an answer because it is not unusual for the fingertips of the right hand to be swollen and bruised after having a cast applied.
Choice D is not an answer because it is not unusual for a child to not keep their arm elevated on a pillow after having a cast applied.
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