A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention?
Negative Doll's eye reflex
Positive Moro reflex
Positive Babinski reflex
Negative Crawl reflex
The Correct Answer is B
A. The negative Doll's eye reflex is normal in infants after a few weeks of life as the reflex should disappear by 2-3 months.
B. The Moro reflex typically disappears by 4-6 months of age. Persistence beyond this age may indicate neurological issues and requires further intervention.
C. The Babinski reflex is normal in infants up to 2 years of age.
D. The crawl reflex may not be consistently present at 9 months, but it is not as concerning as the persistence of the Moro reflex.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While newborns may have incomplete lung expansion, this is not the primary reason for counting for a full minute.
B. The rate and rhythm of breaths in newborns are irregular, so counting for a full minute ensures an accurate assessment.
C. Activity can increase the respiratory rate, but this is true for all age groups and does not explain the need for a full minute count.
D. Newborns are abdominal breathers, but this does not affect the need for a full minute count.
Correct Answer is A
Explanation
A. Withholding fluids until the client demonstrates a gag reflex ensures that the airway is protected and reduces the risk of aspiration.
B. While a humidifier can help keep the throat moist, it does not directly prevent aspiration.
C. Chest physiotherapy is not necessary for preventing aspiration in this scenario.
D. Suctioning the nasopharynx is useful if needed but is not the primary action to prevent aspiration.
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