A nurse is assessing a 15-month-old toddler during a well-child visit. Which of the following findings should the nurse report to the provider?
Displays a positive Babinski reflex
Absent Moro reflex
Refers to self by name
Points to a common object when asked
The Correct Answer is A
Choice A reason: A positive Babinski reflex beyond 12 to 18 months is abnormal and indicates possible neurological dysfunction. At 15 months, the reflex should have disappeared as the nervous system matures. Persistence of this reflex suggests an upper motor neuron lesion or developmental delay, making it a reportable finding.
Choice B reason: The Moro reflex normally disappears by 4 months of age. Its absence at 15 months is expected and does not indicate abnormality.
Choice C reason: Referring to self by name is an appropriate developmental milestone for toddlers around 15 months. It reflects normal language and self-awareness development.
Choice D reason: Pointing to common objects when asked is a normal developmental milestone at this age, showing receptive language and cognitive development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Beef liver is high in cholesterol and saturated fat. Consuming organ meats increases serum cholesterol levels, making this food inappropriate for a client with hypercholesterolemia.
Choice B reason: Egg whites are low in cholesterol and fat, making them a healthy protein source for clients with elevated cholesterol. They provide essential amino acids without contributing to lipid imbalance.
Choice C reason: Steamed clams, while nutritious, are shellfish and contain moderate cholesterol levels. They are not the best recommendation for someone needing to reduce cholesterol intake.
Choice D reason: Broiled lobster, like other shellfish, contains cholesterol and should be limited in a cholesterol-restricted diet. It is not the optimal recommendation compared to egg whites.
Correct Answer is B
Explanation
Choice A reason: The sterile field must always be set up at or above waist level to maintain sterility. Setting it below waist level increases the risk of contamination because the nurse cannot maintain constant visual control.
Choice B reason: Holding the bottle with the palm over the label while pouring prevents solution from running over the label, keeping it legible and dry. This is correct sterile technique and ensures safe handling of sterile solutions.
Choice C reason: Sterile items should be placed at least 2.5 cm (1 in) inside the sterile border. Placing them within 1 cm risks contamination because the edges of the sterile field are considered non-sterile.
Choice D reason: The lid of a sterile solution bottle should be placed face up on a clean surface, not within the sterile field. Placing it in the sterile field contaminates the area.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.