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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Peripheral intravenous (IV) infusion is a common procedure performed on infants in a hospital setting. The selection of the IV site is critical to ensure proper placement and to prevent complications.
When starting a peripheral IV infusion on an infant, the nurse should select a site that is least restrictive to the infant. This involves selecting a site that will not restrict the infant's movement and cause discomfort. The site should be accessible, visible, and easily palpable, such as the hand, wrist, or antecubital fossa.
Assessing the dorsal surface of the feet for an IV site is not recommended as it is an area of high risk for infiltration and may restrict the infant's movement.
Instructing parents to sing or croon to the infant may provide comfort and distraction, but it is not a critical intervention when starting a peripheral IV infusion.
Applying soft restraints to all four extremities is not recommended as it may cause physical and emotional distress to the infant. It should only be used as a last resort if the infant is at high risk of self-injury or if the procedure cannot be safely performed without restraints.
Therefore, the nurse should implement the intervention of selecting a site that is least restrictive to the infant when starting a peripheral IV infusion.
Correct Answer is ["1.8"]
Explanation
The nurse should administer 1.8 mL of diazepam.
To calculate the volume of diazepam to be administered, you would first calculate the total dose of diazepam for this child by multiplying the child's weight (30 kg) by the prescribed dose (0.3 mg/kg). This calculation gives a total dose of 9 mg (30 kg x 0.3 mg/kg = 9 mg). Next, you would divide the total dose (9 mg) by the concentration of the medication (5 mg/mL) to determine the volume to be administered. This calculation gives a volume of 1.8 mL (9 mg / 5 mg/mL = 1.8 mL).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.