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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pulse rate is increased.
While there may be variations in pulse rate due to factors such as activity level and emotional state, a significant increase in pulse rate would not be a typical finding during an annual check- up for an 8-year-old child.
B. Breathing is diaphragmatic.
As children grow older, their respiratory patterns mature, and they develop diaphragmatic breathing, which is deeper and more efficient than the shallow breathing observed in infants. This change would be expected as the child gets older.
C. Secondary sex characteristics are present.
The development of secondary sex characteristics typically occurs during puberty, which begins around the ages of 9 to 13 in girls and 10 to 14 in boys. At 8 years old, it would be unlikely for significant secondary sex characteristics to be present.
D. Blood pressure has reached adult level.
Blood pressure in children gradually increases with age, but it does not reach adult levels until adolescence. At 8 years old, the child's blood pressure would still be within the pediatric range and would not resemble adult levels.
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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