The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Has doubled birth weight.

Plays "peek-a-boo."

Demonstrates startle reﬂex.

Turns head to locate sound.

Answer and Explanation

The Correct Answer is C

The startle reﬂex, also known as the Moro reﬂex, is a normal reﬂex in infants that is present at birth and usually disappears by 3-4 months of age. The reﬂex is elicited by a sudden loud noise or change in position, and the infant will extend their arms and legs, then bring them back in towards their body.

If a 6-month-old infant is still demonstrating the startle reﬂex, it may indicate a developmental delay or neurological issue and requires further evaluation by the nurse or healthcare provider.

The other responses are all normal developmental milestones for a 6-month-old infant. By 6 months of age, most infants will have doubled their birth weight, enjoy playing games like peek-a-boo, and have developed the ability to turn their head to locate sounds.

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Correct Answer is D

Explanation

The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.

A. Oﬀer a pacifier for non-nutritive sucking. B. Use sterile technique during feedings. C. Ensure placement of the enteral tube with an abdominal x-ray. D. Speak to the healthcare provider about instituting physical therapy.

Correct Answer is A

Explanation

To maintain normal growth and development of an infant with a repaired gastroschisis who is receiving parenteral nutrition and continuous enteral feedings, the nurse should include oﬀering a pacifier for non- nutritive sucking in the plan of care. Non-nutritive sucking can help promote the development of the infant's oral motor skills and support normal feeding behaviors. The other options (B, C, and D) are not directly related to maintaining normal growth and development in this situation.

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The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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