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
The client should be instructed to eat a source of sugar if he experiences profuse perspiration, which may indicate hypoglycemia or low blood sugar. Other symptoms of hypoglycemia include shakiness, confusion, dizziness, and weakness.
Eating a source of sugar, such as a glucose tablet, fruit juice, or candy, can quickly raise blood sugar levels and alleviate symptoms of hypoglycemia.
A racing pulse, excessive thirst, and seeing spots are not typically associated with hypoglycemia.
Correct Answer is ["1"]
Explanation
1 teaspoon.
The child has been prescribed loratadine 5 mg once a day. The botle is labeled "Loratadine for Oral Suspension, USP 5 mg per 5 mL." This means that for every 5 mL of the suspension, there is 5 mg of loratadine. Since 1 teaspoon is equivalent to 5 mL, the nurse should instruct the parent to administer 1 teaspoon with each dose to provide the prescribed 5 mg of loratadine.
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