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. While prolonged exposure to peanuts may increase the risk of severe reactions, the severity of the allergy doesn't necessarily worsen due to exposure.
B. The child is only allergic to peanuts, not all types of nuts. Therefore, they may be able to safely eat other nuts, but they must avoid peanuts specifically.
C. Many children outgrow certain food allergies, but peanut allergies tend to persist into adulthood, making it less likely that the child will outgrow it by adolescence.
D. Epinephrine is the first-line treatment for a severe allergic reaction, and carrying an epinephrine auto-injector is essential for managing anaphylaxis quickly if it occurs.
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.
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.