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 A
Explanation
The correct answer is Choice A.
Choice A rationale
The tumbling E chart is used for visual acuity assessment in children who cannot read letters, such as those who are too young or have language barriers. It involves identifying the direction of the letter “E” in various orientations.
Choice B rationale
Testing the child without glasses before testing with glasses is not the standard procedure for visual acuity assessment. The correct approach is to test with the child’s usual corrective lenses if they have them.
Choice C rationale
The standard distance for visual acuity testing using a chart is 3 meters (10 feet) for children, not 4.6 meters (15 feet)9.
Choice D rationale
Assessing each eye separately first, then both eyes together, is the correct procedure for visual acuity testing. This ensures accurate measurement of each eye’s visual acuity.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Administering vaccines prior to discharge is not recommended for a child with neutropenia because their immune system is compromised. Vaccines, especially live vaccines, can pose a risk of infection in immunocompromised individuals.
Choice B rationale
Obtaining the child’s rectal temperature once daily is not advisable for a child with neutropenia. Rectal thermometers can cause mucosal injury and increase the risk of infection in neutropenic patients.
Choice C rationale
Avoiding raw fruits and vegetables in the child’s diet is crucial for a child with neutropenia. Raw fruits and vegetables can harbor bacteria and other pathogens that can cause infections in immunocompromised individuals.
Choice D rationale
Bathing the child every other day is not sufficient for maintaining hygiene in a child with neutropenia. Daily bathing is recommended to reduce the risk of infection by removing potential pathogens from the skin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.