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 C
Explanation
A. Preschoolers typically have a limited understanding of death and may not experience isolation in the way older children or adults do. They may be more concerned about the reactions of those around them rather than feeling isolated.
B. At this stage, preschoolers are more likely to be concerned with bodily functions and their emotional state rather than worrying about physical body changes after death.
C. Preschoolers often perceive death as a form of punishment due to magical thinking. They may believe that death happens because of something they did wrong or something they caused, reflecting a child’s egocentric thinking.
D. Preschoolers generally do not understand the permanence of death. They may believe that the person will return or that they could wake up from a nap. This understanding typically develops around the age of 6.
Correct Answer is A
Explanation
A. Infants with heart failure may experience fatigue during feeding, so smaller, more frequent feedings are recommended to prevent exhaustion and ensure adequate nutrition. Feedings every 3 hours are typically recommended to maintain a steady intake without overexertion.
B. Diluting formula to half strength is not recommended for an infant with heart failure, as it can lead to malnutrition and insufficient caloric intake. The formula should be provided at normal strength.
C. Placing the infant in a lateral position during feeding could be unsafe, as it may increase the risk of aspiration. The infant should generally be fed in an upright or semi-upright position to reduce aspiration risk and promote optimal digestion.
D. Bolus gavage feedings are typically used for infants who are unable to feed orally due to medical conditions, but for a child with heart failure who is feeding orally, more frequent and smaller feedings would be preferable.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.