The nurse is completing an assessment on a 3-month-old male who is in the pediatrician’s office because the infant had a fever and diarrhea for the past 2 days. The infant’s history reveals his mother had preeclampsia and the child was delivered via emergency C-section prematurely at 30 weeks gestation. The nurse performs a history and assessment and finds the following. Which assessment findings require follow-up by the nurse? (Select all that apply)
Unable to roll over back to front
Head lag
Feeding difficulties
Floppy posture
Arms are stiff
Does not smile
Unable to sit without support
Irritable and cries often
Unable to pass an object between hands
Correct Answer : A,B,C,D,E,F,G,H,I
The correct answer is
A. Unable to roll over back to front
B. Head lag
C. Feeding difficulties
D. Floppy posture
E. Arms are stiff
F. Does not smile
G. Unable to sit without support
H. Irritable and cries often
I. Unable to pass an object between hands
Choice A reason
Unable to roll over back to front: At 3 months, infants typically start to develop the ability to roll over from their stomach to their back. Rolling over from back to front usually occurs later, around 4 to 6 months. However, the inability to roll over at all by 3 months could indicate developmental delays or muscle weakness, which requires follow-up.
Choice B Reason
Head lag: By 3 months, infants should have enough neck muscle strength to hold their head up when pulled to a sitting position. Persistent head lag at this age can be a sign of developmental delay or neuromuscular disorders, necessitating further evaluation.
Choice C Reason
Feeding difficulties: Infants should be able to suck and swallow effectively by 3 months. Feeding difficulties can lead to inadequate nutrition and growth, and may indicate underlying issues such as gastrointestinal problems or neurological disorders. This requires prompt attention and intervention.
Choice D Reason
Floppy posture: A 3-month-old should start to show more control over their body movements and have a more stable posture. Floppy posture, also known as hypotonia, can be a sign of various conditions, including genetic disorders, muscle diseases, or central nervous system issues. It is important to investigate the cause of hypotonia.
Choice E Reason
Arms are stiff: Stiffness in the arms, or hypertonia, can indicate neurological problems such as cerebral palsy or other motor disorders. It is crucial to assess the underlying cause of increased muscle tone and provide appropriate interventions.
Choice F Reason
Does not smile: Social smiling typically begins around 6 to 8 weeks of age. If a 3-month-old does not smile, it could be a sign of developmental delay, visual impairment, or other social and emotional issues. This warrants further assessment to determine the cause.
Choice G Reason
Unable to sit without support: While sitting without support is not expected until around 6 months, the inability to show any signs of trying to sit or maintain a sitting position with support at 3 months could indicate developmental delays. This should be monitored and addressed if necessary.
Choice H Reason
Irritable and cries often: Excessive irritability and frequent crying can be signs of discomfort, pain, or underlying medical conditions such as infections, gastrointestinal issues, or neurological problems. It is important to identify and address the cause of the infant’s distress.
Choice I Reason
Unable to pass an object between hands: By 3 months, infants should start to develop hand-eye coordination and the ability to grasp objects. The inability to pass an object between hands may indicate developmental delays or motor skill issues, which require further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Oral rehydration solution (ORS) is the first-line treatment for children with acute diarrhea and moderate dehydration. ORS contains a precise balance of electrolytes and glucose, which helps to rehydrate the child effectively by promoting the absorption of water and electrolytes in the intestines. The World Health Organization (WHO) and the American Academy of Pediatrics recommend ORS as the preferred treatment for dehydration caused by diarrhea. It is effective, easy to administer, and can be given at home or in a healthcare setting.
Choice B reason:
Antidiarrheal medications such as paregoric are not recommended for children with acute diarrhea. These medications can slow down the movement of the intestines, which may prolong the infection and increase the risk of complications. Additionally, they do not address the underlying cause of dehydration. The primary goal in managing acute diarrhea is to rehydrate the child, which is best achieved with ORS.
Choice C reason:
Clear liquids, such as water, broth, or diluted fruit juices, can be used to provide some hydration, but they do not contain the necessary electrolytes to effectively treat moderate dehydration. Clear liquids alone are not sufficient to replace the lost electrolytes and fluids caused by diarrhea. ORS is specifically formulated to address these needs and is more effective in rehydrating the child.
Choice D reason:
Adsorbents, such as kaolin and pectin, are not recommended for the treatment of acute diarrhea in children. These substances can bind to the contents of the intestines and may reduce the frequency of stools, but they do not address the underlying dehydration. The primary focus should be on rehydration with ORS, which provides the necessary electrolytes and fluids to restore the child’s hydration status.
Correct Answer is D
Explanation
The correct answer is d) Central nervous system.
Choice A reason:
The musculoskeletal system is not primarily affected by abnormal phenylalanine levels. Phenylketonuria (PKU) is a metabolic disorder that primarily impacts the brain and cognitive functions. While muscle weakness can occur due to overall health deterioration, it is not the primary system affected by phenylalanine toxicity.
Choice B reason:
The renal system is not the main target of phenylalanine toxicity. Although the kidneys play a role in filtering blood and excreting waste, the toxic effects of phenylalanine accumulation are more pronounced in the brain. Therefore, the renal system is not the primary system affected by abnormal phenylalanine levels.
Choice C reason:
The GI system, or gastrointestinal system, is not the primary system affected by abnormal phenylalanine levels. While dietary management is crucial for individuals with PKU to control phenylalanine intake, the toxic effects are primarily seen in the brain. The GI system is involved in the absorption and digestion of nutrients, but it is not the main system impacted by phenylalanine toxicity.
Choice D reason:
The central nervous system (CNS) is the primary system affected by abnormal phenylalanine levels. Phenylketonuria (PKU) leads to the accumulation of phenylalanine in the brain, causing severe brain damage and cognitive impairments. High levels of phenylalanine can disrupt neurotransmitter synthesis and brain development, leading to intellectual disabilities and other neurological issues. Therefore, the CNS is the main system impacted by phenylalanine toxicity.
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