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 C
Explanation
A. A hemoglobin level of 6.8 g/dL is lower than the normal range for a child (9.5 to 14 g/dL). This indicates anemia, which is a common issue in leukemia due to the disease affecting red blood cell production. Although this level is concerning, it does not necessarily reflect a therapeutic effect of treatment.
B. A WBC count of 15,000/mm³ is elevated compared to the normal range (5,000 to 10,000/mm³). In the context of ALL, high white blood cell counts can indicate active disease or ineffective treatment. Therapeutic effects are generally indicated by a reduction in WBC count towards the normal range.
C. The RBC count of 5/mm³ is within the normal range for a 4-year-old child (4 to 5.5/mm³). This finding suggests that red blood cell production is relatively stable. However, in the context of leukemia treatment, the focus is often on other indicators such as WBC count and platelet count to assess treatment effectiveness
D. A platelet count of 98,000/mm³ is lower than the normal range (150,000 to 400,000/mm³), indicating thrombocytopenia (low platelet count). In children with leukemia, treatment often aims to normalize platelet counts or at least improve them from very low levels.
Correct Answer is C
Explanation
A. While this might seem positive, a newborn is not a playmate for a 3-year-old. This can lead to unrealistic expectations and disappointment.
B. This is not necessary and might create additional stress for the older child. Changes can be made gradually as needed.
C. This is a helpful suggestion. A doll can help the child understand the newborn's needs and prepare for their role as a big sibling.
D. While changes might occur, it's important to maintain as much consistency as possible in the older child's routine to provide a sense of security.
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