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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Administering amphotericin B IV is not indicated for impetigo contagiosa, which is typically treated with topical antibiotics.
B. Applying lidocaine ointment topically is not indicated for impetigo contagiosa and would not address the infection.
C. Initiating contact isolation precautions is appropriate for impetigo contagiosa to prevent the spread of the infection to other patients and healthcare workers.
D. Reporting the disease to the state health department may be necessary for certain communicable diseases but is not the immediate action required in this scenario.

A. Examine the child for skin irritation at the cast edges. B. Restrict the child's strenuous activities for 3 days. C. Monitor for pallor or swelling in the child's affected hand. D. Use a hair dryer on cool setting to relieve itching.

Correct Answer is C

Explanation

A. Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications.
B. Restricting strenuous activities is important for preventing damage to the cast, but it is not the priority over monitoring for circulatory compromise.
C. Monitoring for pallor or swelling in the child's affected hand is the priority because it indicates potential circulatory compromise, which is a critical concern following cast application.
D. Using a hair dryer on a cool setting to relieve itching is a helpful suggestion, but it is not the priority over monitoring for potential complications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has impetigo contagiosa that developed in the hospital. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to the parents of a school-age child following surgery and cast application to the right forearm. Which of the following information is the priority for the nurse to include?

Correct Answer is C

Explanation

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