A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?
Exhibits head lag when pulled to a sitting position
Unable to hold a bottle
Unable to roll from back to abdomen
Absent grasp reflex
The Correct Answer is A
Choice A Reason:
Exhibits head lag when pulled to a sitting position is correct. At 5 months old, infants typically show improvement in head control, and head lag (where the infant's head falls back when pulled to a sitting position) should be diminishing. Persistent head lag might indicate potential developmental concerns or issues with muscle tone that warrant further evaluation by the healthcare provider.
Choice B Reason:
Unable to hold a bottle is incorrect. At 5 months old, some infants might not have developed the ability to hold a bottle independently yet. This skill can vary among infants and might not be a significant concern at this stage.
Choice C Reason:
Unable to roll from back to abdomen is incorrect. Rolling from back to abdomen might not be fully developed in all infants at 5 months old. It's a milestone that some infants achieve later within the 5 to 6-month range, so it might not be an immediate concern unless it persists significantly beyond that range.
Choice D Reason:
Absent grasp reflex is incorrect. By 5 months old, the typical infant's grasp reflex usually starts to diminish as voluntary grasping begins to develop. However, the absence of the grasp reflex might not be an immediate concern unless it's accompanied by other signs of developmental delay or regression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Check oxygen saturation every 4 hr.: While monitoring oxygen saturation is important, in acute epiglottitis, continuous monitoring of oxygen saturation is necessary due to the potential for rapid airway compromise. Intermittent checks every 4 hours may not provide timely information about deteriorating respiratory status.
Choice B Reason:
Obtain a throat culture: While obtaining a throat culture can help identify the causative organism, the priority in acute epiglottitis is securing the airway and stabilizing the child's condition. Attempting a throat culture could provoke agitation or worsen the obstruction due to irritation of the swollen epiglottis.
Choice C Reason:
Initiate droplet isolation precautions: This is an important action because acute epiglottitis is often caused by bacteria, such as Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae, which can spread via respiratory droplets. Isolation precautions help prevent the transmission of the infection to others and protect healthcare workers.
Choice D Reason:
Assist the child into the supine position: In acute epiglottitis, positioning the child supine (lying flat on the back) can worsen the airway obstruction. Keeping the child calm and in a comfortable position that allows easier breathing is important. Sitting the child upright or in a position of comfort that facilitates breathing and minimizes airway obstruction is preferred.
Correct Answer is A
Explanation
Choice A Reason:
Muscle rigidity is correct. Muscle rigidity can indicate several concerning issues postoperatively, such as complications from anesthesia, infection, or other underlying problems. It's crucial to report this finding promptly to the provider for further evaluation and appropriate management.
Choice BReason:
Some degree of abdominal pain is expected post-appendectomy, but the severity and persistence of the pain should be assessed further.
Choice CReason:
Heart rate of 63/min is within the normal range for some adolescents and might not be an immediate concern unless there are other accompanying symptoms.
Choice D Reason:
A temperature of 36.4°C (97.5°F) falls within the normal range for body temperature and might not be a cause for immediate concern unless it's accompanied by other symptoms or if there are signs of temperature changes (like fever) over time.
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