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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Neomycin is not a contraindication to the influenza vaccine. However, if a person has a known neomycin allergy, they should avoid specific vaccines containing neomycin, but this is not typically a concern with the influenza vaccine.

B. Gluten allergies are not a contraindication for the influenza vaccine. Gluten is not an ingredient in most influenza vaccines, so a gluten allergy would not impact vaccine administration.

C. The influenza vaccine contains trace amounts of egg proteins, and individuals who have had a severe allergic reaction (anaphylaxis) to eggs should not receive this vaccine, or they should receive it under close supervision with appropriate precautions. This is because egg-based production methods of the vaccine may pose a risk.

D. Gelatin is a common ingredient in some vaccines, but a gelatin allergy is not typically a contraindication for the influenza vaccine. However, if a child has a severe allergic reaction to gelatin, caution would be taken in administering the vaccine.

A. "You should position your child on their back during administration of the medication." B. "You should add the medication to your child's formula prior to feeding." C. "You should put small bits of ice on your child's tongue prior to administering the medication." D. "You should place the medication along the side of your child's tongue during administration."

Correct Answer is D

Explanation

A. Positioning the child on their back is not recommended, as it could increase the risk of aspiration. It's safer to hold the child in an upright position or slightly reclined, supporting the head and neck.

B. Adding medication to formula or food is not advisable, as the child may not ingest the full dose, and it might not be effective if the child doesn't finish the bottle.

C. While cold may help with taste, it could be difficult for a 1-year-old to handle ice, and it may not effectively improve medication administration.

D. Placing the medication along the side of the child's tongue helps prevent the gag reflex and encourages the child to swallow it more easily, ensuring proper administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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