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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Related Questions
Correct Answer is C
Explanation
A. The Hepatitis B vaccine is typically administered in a series of three doses, starting at birth and continuing through the first year of life. By the age of 5, the child should already have completed the Hepatitis B series. Therefore, this vaccine is not usually administered at this age unless there is a missed dose or special circumstances requiring catch-up.
B. The Hib vaccine is given in a series during infancy and early childhood, with the last dose typically administered between 12 and 15 months of age. By the age of 5, most children should have completed the Hib series. Like Hepatitis B, Hib would not generally be administered at this age unless there are specific catch-up needs.
C. The Varicella (chickenpox) vaccine is part of the routine immunization schedule for children. The first dose is typically given between 12 and 15 months of age, and the second dose is administered between 4 and 6 years of age. At 5 years old, the child would be due for the second dose of the Varicella vaccine if not already received. This makes it a relevant immunization for this age group.
D. The Rotavirus vaccine is given in a series to infants, starting at 2 months of age, with subsequent doses typically given at 4 and 6 months. The series should be completed before the child is 8 months old. By age 5, the child should have already completed the Rotavirus series, so this vaccine would not be administered at this age.
Correct Answer is D
Explanation
A. This statement is appropriate for a 3-year-old. It uses simple language to explain the injection in a way that minimizes fear. Describing the injection as a "little stick" helps to convey that the sensation will be brief and not too painful, which can help reduce anxiety about the procedure.
B. This statement is not advisable because it can place undue pressure on the child to avoid expressing their feelings of discomfort. Additionally, it can create a sense of conditional reward rather than focusing on the purpose of the injection and making the experience more positive.
C. While this statement is well-intentioned, it might be too vague for a 3-year-old. Children at this age may not fully understand the concept of "feeling better" or the purpose of the medication. It is better to use simple and specific language that relates directly to the procedure rather than the outcome.
D. This statement is not appropriate because it offers a choice that is not feasible or relevant to the
child’s immediate situation. For a 3-year-old, the decision about which leg to use is typically made by the healthcare provider based on clinical considerations.
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