During a routine assessment of an 8-month-old, the nurse is assessing primitive reflexes. Which finding should the nurse expect for an infant of this age?

When hearing a loud noise, the infant cries and extends both arms and legs.

When stroking the outer edge of the sole of the infant's foot, the toes fan upward and out.

When infant's head is turned to one side, extension of the same side arm and leg occurs.

When stroking the cheek, the infant turns toward that side of stimulation.

Answer and Explanation

The Correct Answer is B

A. The Moro reflex, where the infant cries and extends both arms and legs in response to a loud noise, typically disappears by 4-6 months of age and would not be expected at 8 months.

B. The Babinski reflex, where the toes fan upward and out when the outer edge of the sole is stroked, is normal in infants and usually disappears by 12-24 months of age.

C. The tonic neck reflex (fencing reflex) typically disappears around 4-6 months of age, so it would not be expected in an 8-month-old.

D. The rooting reflex, where the infant turns their head toward the side of stimulation when the cheek is stroked, typically disappears by 3-4 months of age.

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Correct Answer is B

Explanation

A. Fluid intake is usually restricted to prevent fluid overload, which can worsen edema and hypertension in acute glomerulonephritis.

B. Administering antibiotics may be necessary, especially if the condition is secondary to a streptococcal infection, which is a common cause of acute glomerulonephritis.

C. Rest is typically encouraged rather than frequent ambulation, as activity can exacerbate symptoms.

D. Daily weights, not weekly, are crucial for monitoring fluid balance in acute glomerulonephritis.

A. Decreased urine specific gravity B. Hypotension C. Positive antistreptolysin O titer D. Low blood urea nitrogen and creatinine

Correct Answer is C

Explanation

A. Decreased urine specific gravity is not typical; rather, increased specific gravity may be noted due to concentrated urine.

B. Hypotension is not usually associated with acute glomerulonephritis; hypertension is more common due to fluid retention and renal impairment.

C. A positive antistreptolysin O titer indicates a recent streptococcal infection, which is often the cause of post-streptococcal glomerulonephritis.

D. Elevated blood urea nitrogen (BUN) and creatinine levels are expected due to impaired kidney function, not low levels.

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During a routine assessment of an 8-month-old, the nurse is assessing primitive reflexes. Which finding should the nurse expect for an infant of this age?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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