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?
Doll’s eye reflex intact.
No head lag when pulled to a sitting position.
Presence of tears when crying.
Positive Babinski reflex.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
The presence of the Doll’s eye reflex (oculocephalic reflex) beyond the newborn period is abnormal and should be reported. This reflex should disappear by 2-3 months of age. Its persistence may indicate neurological issues.
Choice B rationale
No head lag when pulled to a sitting position is a normal finding in a 4-month-old infant. By this age, infants typically have developed enough neck muscle strength to hold their head steady.
Choice C rationale
The presence of tears when crying is a normal finding in a 4-month-old infant. Tear production usually begins around 2-3 months of age.
Choice D rationale
A positive Babinski reflex is normal in infants up to 2 years old. It is an expected finding and does not require notification to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Semi-Fowler’s position is not suitable for a lumbar puncture as it does not provide the necessary spinal flexion.
Choice B rationale
The lateral position is ideal for a lumbar puncture as it allows for proper spinal alignment and access to the lumbar region.
Choice C rationale
Supine position is not appropriate for a lumbar puncture as it does not provide the necessary spinal flexion.
Choice D rationale
Prone position is not suitable for a lumbar puncture as it does not allow for proper access to the lumbar region.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Increased capillary refill time is not typically associated with hypoglycemia. It may indicate poor peripheral circulation but is not a common sign of low blood sugar levels.
Choice B rationale
Decreased appetite is not typically associated with hypoglycemia. Hypoglycemia usually causes symptoms such as shakiness, sweating, and confusion.
Choice C rationale
Thirst is not typically associated with hypoglycemia. It is more commonly a symptom of hyperglycemia (high blood sugar levels)9.
Choice D rationale
Shakiness or tremors are common signs of hypoglycemia. When blood sugar levels drop, the body responds by releasing adrenaline, which can cause shakiness.
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