A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?
The infant exhibits a fear of strangers.
The infant understands the word "no".
The infant has an absent grasp reflex.
The infant rolls from their back to their abdomen.
The Correct Answer is C
A. "The infant exhibits a fear of strangers." Stranger anxiety typically develops around 6 to 9 months of age.
B. "The infant understands the word 'no'." Understanding simple words like "no" begins closer to 9 months to 1 year of age.
C. "The infant has an absent grasp reflex." The grasp reflex begins to disappear by 3 months of age, with voluntary grasping developing by 4 to 5 months.
D. "The infant rolls from their back to their abdomen." Rolling from back to abdomen usually occurs around 5 to 6 months.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.
Correct Answer is B
Explanation
A. Administer aspirin for pain. Aspirin increases the risk of bleeding and is contraindicated in clients with hemophilia. Acetaminophen is recommended instead.
B. Place knee pads on the child. Protective gear like knee pads can help prevent joint injuries, which are common in toddlers with hemophilia.
C. Perform passive range-of-motion exercises following an acute episode. Active range-of-motion exercises are preferred after an acute episode to prevent joint damage. Passive exercises can exacerbate bleeding.
D. Use a firm-bristled toothbrush for dental care. A soft-bristled toothbrush should be used to minimize gum bleeding.
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