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. Obtain a detailed history.

Obtaining a detailed history is essential to understand the circumstances surrounding the bruises, including how they occurred, where they are located, and whether there is a plausible

explanation for them. This information helps determine whether the bruises are due to accidental injury or potential abuse.

B. Report the suspected abuse to the authorities.

While reporting suspected abuse may ultimately be necessary if there are concerns about the origin of the bruises, obtaining a detailed history is the initial step to gather information and assess the situation before making a report.

C. Ask a psychiatrist to talk with the parents.

Involving a psychiatrist may be appropriate in cases where there are concerns about the child's mental health or the family dynamics, but it may not address the immediate concern of the bruises without first obtaining a detailed history.

D. Separate the child from the parents.

Separating the child from the parents should not be the first action taken without sufficient evidence or reason to believe that the child is in imminent danger. Gathering information through a detailed history is essential before considering such a drastic measure.

A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." B. "SIDS rates have been rising over the last 10 years." C. "Placing your child on her back when sleeping will decrease the risk of SIDS." D. "Sleep apnea is the main cause of SIDS."

Correct Answer is C

Explanation

A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." - This

statement is incorrect. There is no direct correlation between vaccines and SIDS. In fact, research has shown that vaccines are not a cause of SIDS.

B. "SIDS rates have been rising over the last 10 years." - This statement is misleading. SIDS rates have actually been decreasing over the past few decades due to increased awareness and preventive measures.

C. "Placing your child on her back when sleeping will decrease the risk of SIDS." - This statement is accurate. Placing infants on their backs to sleep is one of the most effective

strategies for reducing the risk of SIDS, according to recommendations from pediatric health organizations.

D. "Sleep apnea is the main cause of SIDS." - This statement is incorrect. While sleep apnea is a sleep-related breathing disorder, it is not the main cause of SIDS. SIDS is a complex phenomenon with multiple contributing factors, but sleep position plays a significant role in reducing its risk.

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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

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Explanation

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Correct Answer is C

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