A nurse is assessing a 5-month-old infant.
Which of the following findings should the nurse report to the provider?
Unable to hold a bottle.
Unable to roll from back to abdomen.
Absent grasp reflex.
Exhibits head lag when pulled to a sitting position.
The Correct Answer is C
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.
Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
Correct Answer is C
Explanation
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy.
This is because the child may be swallowing blood that is coming from the surgical site.
Choice A is wrong because a blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child.
Choice B is wrong because a heart rate of 54/min is within the normal range for a 5-year-old child.
Choice D is wrong because flushing of the face is not an indication of hemorrhage following a tonsillectomy and adenoidectomy.
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