The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

The child does not vocally respond to voices.

The child never squeals or yells.

The child does not babble.

The child does not say dada or mama.

Answer and Explanation

The Correct Answer is C

A. The child does not vocally respond to voices: While vocal responsiveness is an important aspect of development, it may vary among infants and is not necessarily indicative of a developmental problem at 4 months.

B. The child never squeals or yells: Squealing and yelling are vocalizations that infants may or may not exhibit at this age, and their absence alone may not necessarily indicate a developmental problem.

C. The child does not babblE. Babbling, which typically begins around 4 to 6 months of age, involves the repetition of consonant-vowel combinations (e.g., "bababa"). The absence of babbling by 4 months may suggest a delay in language development and could be a potential sign of a developmental problem.

D. The child does not say dada or mamA. Infants may begin to associate "dada" or "mama" with specific caregivers, but this typically occurs later, closer to 6 to 9 months of age. The absence of this behavior at 4 months may not necessarily indicate a developmental problem.

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Correct Answer is A

Explanation

A. A child whose parents answer questions for the child. This behavior may indicate that the child's parents are controlling or dominating, possibly preventing the child from expressing their own thoughts or feelings. It could be a sign of emotional or psychological abuse, where the child's autonomy and voice are suppressed.

B. A child who has frequent visitors: While frequent visitors may raise concerns about the child's social environment, it does not necessarily indicate abuse. Further assessment would be needed to determine the nature of these visits and their impact on the child's well-being.

C. A child who uses the call light frequently: Frequent use of the call light may indicate physical discomfort, illness, or anxiety, but it does not inherently suggest abuse. It could be related to the child's medical condition or emotional state.

D. A child who has a BMI indicating obesity: Obesity alone is not indicative of abuse. While it may raise concerns about the child's health and well-being, it does not directly point to abuse unless there are additional signs or symptoms suggestive of neglect or mistreatment.

A. "This is a primitive reflex known as the palmar grasp." B. "This is a protective reflex known as rooting." C. "This is a primitive reflex known as the plantar grasp." D. "This is a protective reflex known as the Moro reflex."

Correct Answer is A

Explanation

A. "This is a primitive reflex known as the palmar grasp.": The palmar grasp reflex is a primitive reflex observed in newborns where they automatically grasp onto objects (or fingers) that touch

their palms. This reflex typically disappears by around 6 months of age.

B. "This is a protective reflex known as rooting.": Rooting is a reflex where newborns turn their head and open their mouth in response to cheek or mouth stimulation, facilitating breastfeeding. It is not related to grasping objects with the hands.

C. "This is a primitive reflex known as the plantar grasp.": The plantar grasp reflex is similar to the palmar grasp but occurs when pressure is applied to the sole of the foot. It is unrelated to grasping objects with the hands.

D. "This is a protective reflex known as the Moro reflex.": The Moro reflex, also known as the startle reflex, involves the newborn's arms and legs extending and then flexing in response to a sudden movement or loud noise. It is not related to grasping objects with the hands.

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The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Correct Answer is A

Explanation

A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?

Correct Answer is A

Explanation

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