A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
Doll's eye reflex intact
No head lag when pulled to a sitting position
Positive Babinski reflex
Presence of tears when crying
The Correct Answer is A
A. The doll's eye reflex, or oculocephalic reflex, is a normal reflex in infants up to about 2 months of age. It involves the eyes moving in the opposite direction of head movement. By 4 months of age, this reflex
typically disappears as the infant’s voluntary eye movements become more developed. Therefore, if the
B. By 4 months of age, it is normal for an infant to show significant reduction in head lag when pulled to a sitting position. Ideally, the infant should be able to hold their head up with minimal lag.
C. The Babinski reflex is a normal reflex in infants, where the toes fan out when the sole of the foot is stroked. This reflex is expected to be positive in infants up to about 12-24 months of age. By 4 months, a positive Babinski reflex is still normal and does not indicate a problem.
D. Infants typically start producing tears around 2-3 months of age. By 4 months, the presence of tears when crying is a normal developmental milestone and indicates healthy lacrimal gland function. Therefore, this finding is normal and does not need to be reported to the provider.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
A. Educate the child about proper perineal hygiene. Anticipated. This is essential to prevent the recurrence of UTIs.
B. Advise child's guardian about the use of sunscreen. Anticipated. While not directly related to the UTI, protecting the child's skin from sun damage is important overall health.
C. Administer salicylic acid for pain and fever. Contraindicated. Salicylic acid is contraindicated in children due to the risk of Reye's syndrome.
D. Administer sulfamethoxazole and trimethoprim. Anticipated. This is the prescribed medication for the UTI and should be administered as ordered.
E. Ensure the child receives a maximum of 1,200 mL/day of fluid. Anticipated. Adequate hydration is crucial for flushing bacteria from the urinary tract. Restricting fluids is counterproductive.
Correct Answer is D,B,C,A
Explanation
D. Before using the inhaler, the child should exhale fully to empty the lungs and ensure that the medication can be effectively inhaled. This step prepares the airways to receive the medication.
B. As the child starts to inhale slowly and deeply through the mouthpiece, they should simultaneously depress the canister to release the medication. This coordinated action ensures that the medication is delivered into the lungs.
C. After inhaling the medication, the child should hold their breath for about 10 seconds (or as long as comfortable). This allows the medication to settle in the airways and improves its effectiveness.
A. After holding the breath, the child can remove the inhaler from their mouth. This step concludes the inhalation process and allows the child to exhale normally.
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