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 D
Explanation
A. Using a dime-sized amount of the medication is not the recommended instruction for tretinoin. A small, pea-sized amount is typically advised to avoid irritation and overuse.
B. Tretinoin should be applied at night, not in the morning, as it increases sensitivity to sunlight and can cause irritation when exposed to sunlight.
C. It is generally recommended to wait 20-30 minutes after washing the face before applying tretinoin, not just 5 minutes. This allows the skin to dry completely, reducing irritation.
D. Tretinoin can cause skin sensitivity, making the skin more prone to sunburn. Using a sunscreen with SPF 15 or higher is crucial to protect the skin from harmful UV rays while using tretinoin.
Correct Answer is D
Explanation
A. Redness at the injection site is a common and mild reaction to vaccines. It does not typically require immediate medical intervention unless it worsens or is accompanied by more severe symptoms.
B. A temperature of 37.7° C (99.9° F) is a low-grade fever, which is a common, expected response after immunization. It is not a priority unless it increases significantly or is accompanied by other concerning symptoms.
C. Prolonged crying can sometimes occur after immunizations, but it is usually self-limited and resolves within a short period. If the crying is not excessive and does not indicate distress, it is generally not a priority concern.
D. Hives on the child’s neck could be a sign of an allergic reaction, such as anaphylaxis, which is a medical emergency. The nurse should immediately assess the child’s airway and provide necessary interventions, such as administering epinephrine, if required. This finding is the priority because it suggests a possible severe allergic response
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