A 9-month-old infant is inconsolable and repeatedly tugs at the right ear. The infant also cries when lying down. What is the nurse's best action to determine the source of pain?
Gently assess the ear and check for redness, swelling, or drainage
Administer pain medication without further assessment
Assume the pain is generalized to the entire head
Ask the infant to point to where it hurts
The Correct Answer is A
A. Gently assess the ear and check for redness, swelling, or drainage is correct. The infant’s symptoms, tugging at the ear, inconsolable crying, and increased pain when lying down, are classic signs of acute otitis media (ear infection). A careful, gentle assessment of the external ear and ear canal for redness, swelling, or drainage helps determine the source of pain and guides appropriate treatment.
B. Administer pain medication without further assessment is incorrect because pain management should follow an assessment to identify the underlying cause. Treating pain without understanding the source may delay diagnosis and appropriate treatment, such as antibiotics if indicated.
C. Assume the pain is generalized to the entire head is incorrect because infants often cannot verbalize pain location, but the pattern of ear tugging and positional crying provides important diagnostic clues. Making assumptions without assessment risks misdiagnosis.
D. Ask the infant to point to where it hurts is incorrect because a 9-month-old cannot reliably indicate the location of pain, making observation and gentle physical assessment essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.96"]
Explanation
Step 1: Divide the ordered dose by the available dose
400 ÷ 500 = 0.8
Step 2: Multiply by the available volume
0.8 × 1.2 = 0.96
Correct Answer is A
Explanation
A. Infant can hold head steady before rolling over is correct because cephalocaudal growth and development occur from head to toe. Control of the head and neck muscles develops first, followed by control of the trunk and then the lower extremities. Being able to hold the head steady is an early milestone that clearly demonstrates cephalocaudal progression.
B. Infant can pick up small objects with thumb and forefinger is incorrect because this describes development of the pincer grasp, which reflects fine motor development and typically occurs later (around 9–12 months). It does not specifically demonstrate cephalocaudal progression.
C. Infant can sit independently is incorrect because sitting requires trunk and core muscle control, which develops after head control. While related to cephalocaudal development, it is not the best example because it occurs later in the sequence.
D. Infant can crawl using arms and legs simultaneously is incorrect because crawling involves coordinated use of both upper and lower extremities, which occurs later in infancy and reflects overall motor coordination rather than early head-to-toe development.
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