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 A
Explanation
A. Children with asthma are at an increased risk for respiratory infections, including pneumococcal infections. Therefore, pneumococcal immunization is recommended for children with asthma to help prevent pneumonia and other infections.
B. Salmeterol is a long-acting beta-agonist used for asthma maintenance and not for acute exacerbations. The nurse should instruct the guardian to use a quick-relief bronchodilator (e.g., albuterol) for acute symptoms.
C. When using a peak flow meter, the child should inhale as deeply as possible, but the exhalation should be long and forceful. Inhaling quickly may not give an accurate reading of lung function.
D. Physical activity and sports are important for children with asthma, as long as their asthma is well controlled. The nurse should not recommend avoiding school sports unless the child has an active exacerbation or poor asthma control.
Correct Answer is B
Explanation
A. Wiping from the outer corner of the eye to the inner canthus is incorrect because this can introduce bacteria from the outer part of the eye into the inner part, which could exacerbate the infection. The proper technique is to wipe from the inner canthus to the outer canthus to prevent contamination.
B. Cleaning the eye with a moist cloth is appropriate for conjunctivitis as it helps remove secretions and crusts that accumulate. Using a clean, moist cloth minimizes irritation to the eye.
C. Keeping the eye covered with a compress is not recommended unless directed by a provider. Compresses could increase irritation or harbor bacteria if not kept clean.
D. Applying eye ointment in the morning is not optimal because ointment should generally be applied at night to prevent blurred vision during the day. The nurse should advise applying it as prescribed by the healthcare provider.
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