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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice AReason:

Measles, mumps, and rubella (MMR) vaccine is important for general immunity, but it might not be specifically emphasized for an adolescent with sickle cell anemia unless they have missed these vaccinations previously.

Choice BReason:

Respiratory syncytial virus (RSV) vaccine is often recommended for infants at high risk for severe RSV infection but may not be a primary concern for an adolescent with sickle cell anemia.

Choice CReason:

Pneumococcal conjugate (PCV13) would be an important immunization to include in the plan for an adolescent with sickle cell anemia. Sickle cell disease increases the risk of infections, particularly with encapsulated bacteria like Streptococcus pneumoniae, which the PCV13 vaccine covers. This immunization helps prevent pneumonia, meningitis, and other invasive pneumococcal diseases.

Choice DReason:

Rotavirus vaccine is typically administered in infancy and might not be relevant for an adolescent population.

A. Exposure to secondhand smoke B. Decreased temperature C. Lack of sleep D. Prolonged headache

Correct Answer is C

Explanation

Choice AReason:

Exposure to secondhand smoke is incorrect. While exposure to secondhand smoke isn't healthy for anyone, it might not be a primary trigger for seizures in most cases. However, for some individuals, exposure to certain environmental toxins or irritants might exacerbate their condition, though this varies from person to person.

Choice BReason:

Decreased temperature is incorrect. While extreme temperatures (both hot and cold) can potentially trigger seizures in some individuals, decreased temperature alone might not be a common trigger compared to other factors.

Choice C Reason:

Lack of sleep is correct. Sleep deprivation can be a significant trigger for seizures in people with epilepsy or seizure disorders. Maintaining a regular sleep schedule and ensuring adequate sleep is an important aspect of managing seizures in these individuals.

Choice D Reason:

Prolonged headache is incorrect. Headaches can sometimes be a warning sign or an aura before a seizure for some individuals, but having a headache alone might not directly trigger a seizure for most people with a seizure disorder. However, there can be a relationship between headaches and certain types of seizures in specific cases.

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A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

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