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 B
Explanation
When using an ophthalmic anti-infective ointment, it is important to prepare the child for blurry vision after ointment application. This is because the ointment can temporarily blur vision after application. It is important to follow the instructions on the medication label and continue using the ointment for the full course of treatment, even if symptoms improve before then ¹.
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.
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