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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.
B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of
dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.
C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.
D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.
Correct Answer is A
Explanation
A. Stands on one foot for a few seconds: By age 3, children typically begin to develop the ability to stand briefly on one foot, although they may not be able to maintain balance for an extended period.
B. Skips and hops on one foot: Skipping and hopping on one foot are more advanced gross motor skills that usually develop around ages 4 to 5, so it would be less expected for a 3-year-old.
C. Walks backwards heel to toE. Walking backwards heel to toe requires a higher level of coordination and balance and is usually mastered later in childhood, typically around ages 4 to 6.
D. Has a vocabulary of 1,500 words: While vocabulary development varies among children, a vocabulary of 1,500 words would be advanced for a 3-year-old. Most children at this age have a vocabulary of around 200 to 1,000 words.
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