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 C

Explanation

To determine a possible urinary tract infection in a preschool-aged child who presents with ﬂank pain, dysuria, and low-grade fever, the nurse should gather additional information from the parent about new onset bedwetting. New onset bedwetting can be a sign of a urinary tract infection in children. The other options (A, B, and D) are not directly related to determining a possible urinary tract infection in this situation.

A. Apply lotion to hands and feet. B. Encourage the child to rest when possible. C. Place the child in a quiet environment. D. Make a list of foods that the child likes.

Correct Answer is C

Explanation

The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inﬂammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child's symptoms. The other options (A, B, and D) may also be helpful, but placing the child in a quiet environment is a key intervention 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

The nurse is assessing a preschool-aged child who presents with ﬂank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

Correct Answer is C

Explanation

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

Correct Answer is C

Explanation

Which snack selected by a school-aged child with gastroesophageal reﬂux indicates to the nurse that the child understands the dietary restrictions?

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The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

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