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 B

Explanation

The nurse should include rice in the list of allowed foods for a child who is newly diagnosed with celiac disease. Rice is a gluten-free grain and is safe for individuals with celiac disease to consume. Rye, oats, and barley all contain gluten and should be avoided by individuals with celiac disease. However, some individuals with celiac disease may be able to tolerate oats that are certified gluten-free and not contaminated with other gluten-containing grains.

A. Audible heart murmur. B. Heart rate of 162 beats/minute. C. Poor oral intake and suckling eﬀort. D. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.

Correct Answer is C

Explanation

Infants with congenital heart defects may have difficulty with feeding due to increased eﬀort required to breathe and feed at the same time. This can lead to poor weight gain and dehydration. Thus, it is important for the nurse to report any signs of poor feeding or oral intake to the healthcare provider. While audible heart murmur (choice A)and a high heart rate (choice B)are expected findings in infants with congenital heart defects, they do not necessarily indicate a need for immediate intervention. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours (choice D)may actually be a positive finding in an infant with a congenital heart defect, but it is not as important to report as poor oral intake and suckling eﬀort.

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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 teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?

Correct Answer is B

Explanation

The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

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

The nurse is caring for a toddler with autism spectrum disorder and failure to thrive. Which intervention should the nurse implement?

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A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?