The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

The child exhibits plantar grasp reflex.

The child has doubled his birth weight.

No primary teeth have erupted yet.

The child's head circumference is 49.53 cm.

Answer and Explanation

The Correct Answer is C

A. The child exhibits plantar grasp reflex: The presence of the plantar grasp reflex at 10 months

is appropriate and not cause for concern. This reflex typically diminishes by around 9 months but can persist slightly longer in premature infants.

B. The child has doubled his birth weight: Doubling birth weight by around 6 months is a normal developmental milestone, and achieving this by 10 months is appropriate, indicating healthy growth.

C. No primary teeth have erupted yet: The absence of primary teeth by 10 months, especially in a preterm infant, may indicate a delay in dental development and should prompt further evaluation by a healthcare provider.

D. The child's head circumference is 49.53 cm: The head circumference of 49.53 cm falls within the typical range for a 10-month-old infant and is not inherently concerning.

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Correct Answer is A

Explanation

A. A child whose parents answer questions for the child. This behavior may indicate that the child's parents are controlling or dominating, possibly preventing the child from expressing their own thoughts or feelings. It could be a sign of emotional or psychological abuse, where the child's autonomy and voice are suppressed.

B. A child who has frequent visitors: While frequent visitors may raise concerns about the child's social environment, it does not necessarily indicate abuse. Further assessment would be needed to determine the nature of these visits and their impact on the child's well-being.

C. A child who uses the call light frequently: Frequent use of the call light may indicate physical discomfort, illness, or anxiety, but it does not inherently suggest abuse. It could be related to the child's medical condition or emotional state.

D. A child who has a BMI indicating obesity: Obesity alone is not indicative of abuse. While it may raise concerns about the child's health and well-being, it does not directly point to abuse unless there are additional signs or symptoms suggestive of neglect or mistreatment.

A. Describing the tongue extrusion reflex B. Explaining how to prepare table meats C. Advising about increased caloric needs D. Discussing the type of sippy cup to use

Correct Answer is C

Explanation

A. Describing the tongue extrusion reflex: The tongue extrusion reflex is typically present in

infants up to around 4 to 6 months of age and diminishes as they begin to eat solid foods. At 7 months, this reflex is likely no longer prominent.

B. Explaining how to prepare table meats: While introducing solid foods is important around 6 months of age, meats are often introduced later in infancy due to their texture and potential

allergenicity. At 7 months, infants may still be primarily consuming pureed or mashed foods.

C. Advising about increased caloric needs: At 7 months, infants are transitioning to a more varied diet that includes solid foods alongside breast milk or formula. Guidance on meeting their

increasing nutritional needs is crucial at this stage.

D. Discussing the type of sippy cup to usE. Sippy cups are typically introduced closer to the end of the first year or during the transition to weaning from the bottle. While it's important to

discuss appropriate feeding utensils, addressing increased caloric needs is a more immediate concern for a 7-month-old infant.

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The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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