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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Soy milk is not recommended for infants under one year of age. It does not provide the necessary nutrients for their growth and development.
B. Commercially prepared infant formula is specifically designed to meet the nutritional needs of infants. It is the best alternative to breast milk for infants having difficulty eating.
C. While warming milk might be comforting, it does not address the underlying issue of goat milk being an inappropriate nutritional source for a 10-month-old infant.
D. Breast milk is the best source of nutrition for infants. However, if breastfeeding is not possible, formula is the next best option.
Correct Answer is D
Explanation
A. Morphine is more likely to cause hypotension (low blood pressure), not hypertension.
B. Stevens-Johnson syndrome is a severe allergic reaction not typically associated with morphine.
C. Prolonged wound healing is often associated with corticosteroids, not opioids like morphine.
D. Bradypnea (slowed breathing) is a common adverse effect of opioids, including morphine. It's crucial to monitor respiratory rate and depth closely in patients receiving morphine.
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