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 C
Explanation
A. Pediculosis capitis (head lice) does not require droplet precautions.
B. Viral conjunctivitis (pink eye) is typically spread through direct contact or contact with contaminated surfaces, not droplets.
C. Seasonal influenza is a respiratory illness that can spread through droplets when the infected person coughs or sneezes, necessitating droplet precautions.
D. Hepatitis A is primarily spread through the fecal-oral route and does not require droplet precautions.
Correct Answer is B
Explanation
A) An increase in potassium levels is not an expected finding with furosemide; instead, hypokalemia is a potential side effect.
B) Furosemide is a diuretic commonly used to decrease fluid retention and edema, so a decrease in peripheral edema would indicate the medication's effectiveness.
C) A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart failure.
D) An increase in venous pressure would suggest venous congestion, which is not an indication of effective furosemide therapy.
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