A nurse is collecting data on a 1-month-old infant during a well-child visit. Which of the following findings should the nurse expect?
Absent rooting reflex
Respiratory rate 64/min
Head lag
Yellow sclera
The Correct Answer is C
A. The rooting reflex should be present at 1 month of age, not absent. This reflex is triggered when the infant’s cheek is stroked, prompting the baby to turn their head toward the stimulus and open their mouth.
B. A respiratory rate of 64/min is within the expected range for a 1-month-old infant, whose normal respiratory rate is typically between 30–60 breaths per minute.
C. Head lag is normal at 1 month of age when the infant's head is lifted while they are in a sitting position. However, by 4 months of age, the infant should have more head control and reduced head lag.
D. Yellow sclera indicates jaundice, which is common in newborns but should be assessed if present at 1 month to ensure it resolves. By this time, any jaundice should be resolving or gone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Rice milk is a good alternative for someone with lactose intolerance as it is lactose-free and does not cause digestive discomfort.
B. Flavored yogurt may still contain lactose, and the added sugar can make it less ideal for someone with lactose intolerance. Plain yogurt, however, may be easier to digest for some individuals because it contains live cultures that help break down lactose.
C. Gradually increasing lactose-containing products is not recommended for someone with lactose intolerance. The goal is typically to avoid or limit lactose to prevent symptoms.
D. Calcium-fortified orange juice is a good source of calcium for individuals with lactose intolerance and does not need to be limited unless the individual has other dietary restrictions.
Correct Answer is C
Explanation
A. Aspirin is contraindicated for children due to the risk of Reye's syndrome, a potentially fatal condition associated with aspirin use in children under the age of 18.
B. Administering acetaminophen at this frequency could result in overdose or liver damage, especially in children. Acetaminophen should be given at appropriate intervals (usually every 4–6 hours) as per the prescribed dosage.
C. Lowering the temperature of the room can help reduce the child’s fever without overcooling. A comfortable room temperature helps to prevent further heat retention and promotes the child's comfort.
D. An ice bath can cause shivering, which could raise the body temperature and cause additional harm. It is not recommended for fever reduction in children.
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