During a well-baby check, the nurse recognizes the presence of what as indicative of appropriate neurological development?
Appropriate weight
Vernix caseosa
Presence of lanugo
Expected reflexes
The Correct Answer is D
Choice A reason: This is not an indicator of appropriate neurological development. Appropriate weight is a measure of the physical growth and nutritional status of the baby. It is influenced by the baby's genetics, gestational age, birth weight, feeding habits, and health conditions. Appropriate weight does not reflect the baby's brain development or function.
Choice B reason: This is not an indicator of appropriate neurological development. Vernix caseosa is a white, cheesy substance that covers the skin of the baby in the womb. It protects the skin from the amniotic fluid and helps with temperature regulation and infection prevention. Vernix caseosa is mostly shed before or during birth, and does not relate to the baby's brain development or function.
Choice C reason: This is not an indicator of appropriate neurological development. Presence of lanugo is a fine, soft hair that covers the body of the baby in the womb. It helps to keep the baby warm and hold the vernix caseosa on the skin. Presence of lanugo is usually lost before or shortly after birth, and does not indicate the baby's brain development or function.
Choice D reason: This is the best answer. Expected reflexes are involuntary movements or responses that the baby makes in reaction to certain stimuli. They are controlled by the nervous system and indicate the baby's brain development and function. Expected reflexes include the rooting, sucking, grasping, Moro, and Babinski reflexes. The nurse should assess the presence, strength, and symmetry of these reflexes during the well-baby check.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is a partial answer. It is helpful in understanding client actions, but it is not the main reason for nurses to understand growth and developmental stages.
Choice B reason: This is a vague answer. It provides important background information, but it does not explain how that information is used in nursing practice.
Choice C reason: This is the best answer. It helps in planning interventions that will result in best outcomes, because it allows the nurse to tailor the care to the client's specific needs, abilities, and expectations based on their stage of growth and development.
Choice D reason: This is a weak answer. It is important to teach the client about what stage they are in, but it is not the primary reason for nurses to understand growth and developmental stages. Teaching the client about their stage of growth and development may be one of the interventions that the nurse plans, but it is not the goal of understanding growth and developmental stages.
Correct Answer is D
Explanation
Choice A reason: This is not a statement that shows an understanding of safety. A fluffy pillow can pose a suffocation risk for a 10-month old baby, who may not be able to move their head away from it. The nurse should educate the parent on the safe sleep practices for infants, such as placing the baby on their back, using a firm and flat surface, and avoiding soft bedding and toys in the crib.
Choice B reason: This is not a statement that shows an understanding of safety. A car seat on the table can be unstable and fall off, causing injury to the baby. The nurse should instruct the parent on the proper use and installation of the car seat, such as securing it in the back seat of the car, facing the rear, and using the harness straps and clips correctly.
Choice C reason: This is not a statement that shows an understanding of safety. Whole milk is not recommended for a 10-month old baby, who may not be able to digest it well and may develop an allergy or intolerance. The nurse should advise the parent on the appropriate nutrition for infants, such as breastfeeding or formula feeding until 12 months, and introducing solid foods gradually and with caution.
Choice D reason: This is the best answer. A crib mattress in the low position is safer for a 10-month old baby, who may be able to pull themselves up and try to climb out of the crib. The nurse should commend the parent on this action and remind them to check the crib for any hazards, such as loose screws, gaps, or sharp edges.
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