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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?

A.

No head lag when pulled to a sitting position

B.

Doll's eye reflex intact

C.

Presence of tears when crying

D.

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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Related Questions

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

Correct Answer is A

Explanation

A. This finding is consistent with both acute laryngotracheobronchitis and pneumonia, as both conditions can cause discomfort and distress in children.
B. Fever can be present in both acute laryngotracheobronchitis and pneumonia as they are both infections of the respiratory tract. It is a non-specific symptom that can occur with various respiratory illnesses.
C. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis is characterized by a barking, non-productive cough that worsens at night or with agitation, while pneumonia causes a productive cough that may be accompanied by chest pain or difficulty breathing.
D. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis causes inflammation and narrowing of the upper airway, leading to a high-pitched sound during inhalation, while pneumonia affects the lower airway and does not usually cause stridor.

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