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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?

A.

Absent rooting reflex

B.

Respiratory rate 64/min

C.

Head lag

D.

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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Related Questions

Correct Answer is A

Explanation

A. A 9-month-old infant is expected to demonstrate a crude pincer grasp, which involves picking up small objects between the thumb and forefinger. This is a developmental milestone for this age.

B. While infants may shake their heads by this age, it is typically not used in the context of saying "no." This action is usually a sign of exploration or reaction to stimulation.

C. A 9-month-old typically does not use two-word phrases. By this age, infants are usually babbling and may say single words like "mama" or "dada."

D. A 9-month-old is not expected to build a tower of four blocks. By 12-15 months, infants may begin to stack blocks.

Correct Answer is C

Explanation

A. Massaging the injection site is not recommended, as it can cause irritation or tissue damage, especially after certain types of injections.

B. The dorsogluteal muscle is no longer recommended for vaccine administration due to the risk of injury to the sciatic nerve. The preferred site is the vastus lateralis or deltoid muscle.

C. It is essential to ensure that the guardian has signed an informed consent form prior to administering the vaccine. This confirms that the guardian is aware of the vaccine's benefits and potential risks.

D. Aspirating for blood return before administering vaccines is no longer recommended or necessary for intramuscular injections.

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