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?
No head lag when pulled to a sitting position
Doll's eye reflex intact
Presence of tears when crying
Positive Babinski reflex
The Correct Answer is B
A. No head lag when pulled to a sitting position is a normal finding at 4 months of age.
B. They should not have doll's eye reflex intact, which means that their eyes move in the opposite direction of their head when turned. This reflex normally disappears by 3 months of age and its persistence may indicate brain damage.
C. The presence of tears when crying is a normal finding at 4 months of age.
D. They should also have positive Babinski reflex, which means that their toes fan out when their sole is stroked. This reflex normally disappears by 12 months of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
Correct Answer is D
Explanation
A. Offering sips of water 4 hours following surgery may be too early and could increase the risk of postoperative complications such as nausea and vomiting.
B. Assisting the adolescent to ambulate 12 hours following surgery may be too early depending on the surgical procedure and the adolescent's condition.
C. Maintaining the head of the bed at a 30° angle is incorrect because this position increases pressure on the spinal cord and can cause complications.
D. Logrolling the adolescent every 2 hours prevents spinal injury and promotes healing by keeping the spine in alignment
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