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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Accompany verbal instructions with visual references. Children with ADHD benefit from multimodal teaching strategies. Combining verbal instructions with visual aids helps reinforce understanding and keeps the child focused.
B. Vary the classroom routine to keep the children interested: Children with ADHD thrive on consistency; frequent changes in routine can increase confusion and distractibility.
C. Limit presentation of subjects of interest to the afternoons: This is not evidence-based. Children’s ability to focus varies throughout the day, and important content should not be restricted to a specific time.
D. Increase classroom assignments to stimulate learning: Increasing workload can overwhelm a child with ADHD, leading to frustration and reduced engagement.
Correct Answer is C
Explanation
A. Passive range of motion exercises are contraindicated during acute joint swelling and bleeding, as they can exacerbate bleeding into the joints (hemarthrosis).
B. Aspirin is contraindicated as it can impair platelet function and worsen bleeding in clients with bleeding disorders.
C.Offering an electronic tablet helps to distract the toddler and prevent unnecessary movement, which could worsen joint bleeding or discomfort.
D. Warm packs are contraindicated during acute joint swelling; cold packs should be used to reduce bleeding and swelling.
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