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 D
Explanation
Choice A Reason:
Acknowledge the family members' feelings of guilt. While it's important to validate the family's feelings and provide emotional support, assuming or acknowledging guilt without evidence could be harmful. Instead, the nurse should offer empathy and support without attributing blame.
Choice B Reason:
Discourage the parents from allowing siblings to view the body. The decision of whether siblings should view the body is personal and should be respected based on the family's beliefs and preferences. The nurse should offer guidance and support, allowing the family to make an informed decision.
Choice C Reason:
Avoid discussing details of the attempt to revive the infant. Discussing the attempt to revive the infant might help the family understand the medical interventions performed and the efforts made. However, it should be approached with sensitivity and based on the family's readiness to receive such information.
Choice D Reason:
Provide a follow-up phone call 1 week following the infant's death. Following up with the family after a week allows for ongoing support, assessment of their emotional well-being, and providing additional resources or guidance as needed during the grieving process.
Correct Answer is C
Explanation
Correct answer: C
Choice A Reason:
Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.
Choice B Reason:
Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.
Choice C Reason:
Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.
Choice D Reason:
Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.
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