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 A
Explanation
Choice A Reason:
"Let me know when you want to take the medication.": This statement offers the child autonomy and control over the situation, allowing them to feel empowered to decide when to take the medication.
Choice B Reason:
"The medication isn't bad. It tastes like candy.": This statement might be misleading, as medications often don't taste like candy. It's important to maintain honesty with children about the taste of medication to build trust.
Choice C Reason:
"The medication will treat your hypersensitivity reaction.": While it's important to explain the purpose of the medication, this statement might not resonate well with a preschooler. Using simpler language and a more relatable explanation might be more effective.
Choice D Reason:
"Sometimes, when a child has to take medication, they feel sad.": This statement acknowledges the child's feelings, but it might inadvertently suggest negative emotions associated with taking medication. Instead, it's often better to use positive and reassuring language.
Correct Answer is C
Explanation
Choice A Reason
Pulse rate 98/min: A pulse rate of 98 beats per minute is within the expected range for a 2-year-old child (normal range: 70-110 bpm). This finding is generally considered normal for this age and may not require immediate reporting.
Choice B Reason:
Temperature 37.2° C (99° F): A temperature of 37.2°C (99°F) is slightly elevated but is within the range of low-grade fever in children. However, at a well-child visit, this temperature might not be immediately alarming, especially if the child doesn't exhibit other signs of illness.
Choice C Reason:
Blood pressure 118/74 mm Hg:This reading is higher than the normal range for a 2-year-old child. High blood pressure in a young child should be evaluated further to determine the cause and need for intervention.
Choice D Reason:
Respiratory rate 26/min: The normal respiratory rate for a 2-year-old child typically ranges from 20 to 30 breaths per minute. A respiratory rate of 26 breaths per minute is within this range and may not warrant immediate concern.
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