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. Weighing the child weekly is not an appropriate intervention for managing acute diarrhea, as it does not address the immediate concern of dehydration or infection.
B. Keeping the child NPO for 12 hours is generally not recommended unless the child is severely dehydrated or vomiting, as it could lead to further dehydration. Hydration and appropriate refeeding are important in managing diarrhea.
C. A stool culture can help determine the cause of diarrhea (such as bacterial infection) and guide appropriate treatment. This is a priority in determining the underlying cause of the child's symptoms.
D. Offering apple juice is not recommended for diarrhea, as high fructose content can worsen diarrhea. Oral rehydration solutions (ORS) or clear fluids are more appropriate.
Correct Answer is "{\"xRanges\":[89.828125,109.828125],\"yRanges\":[84,104]}"
Explanation
A. The nurse should expect the rash to appear first on the child's cheeks. Erythema infectiosum, also known as fifth disease, typically begins with a bright red rash on the cheeks, giving the appearance of "slapped cheeks"
B. This is often followed by a lacy, red rash that can spread to the arms, legs, and trunk
C. This is often followed by a lacy, red rash that can spread to the arms, legs, and trunk
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