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.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Partial thromboplastin time (PTT) is not typically used in the diagnosis of rheumatic fever.
B. C-reactive protein (CRP) is elevated in cases of inflammation and can help confirm the diagnosis of rheumatic fever.
C. Erythrocyte sedimentation rate (ESR) is another marker of inflammation that can be elevated in rheumatic fever.
D. Antistreptolysin O (ASO) titer measures antibodies against streptolysin O produced by Group A Streptococcus, which can indicate recent streptococcal infection, contributing to the diagnosis of rheumatic fever.
E. Blood urea nitrogen (BUN) is not directly related to the diagnosis of rheumatic fever.
Correct Answer is A
Explanation
A) Oral electrolyte solution helps prevent dehydration and replaces lost electrolytes in infants with acute diarrhea, making it the most appropriate choice.
B) Applesauce may worsen diarrhea due to its high sugar content.
C) White grape juice is also high in sugar and may worsen diarrhea.
D) Chicken soup is not recommended as it may be too heavy and rich for an infant with acute diarrhea.
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