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.
Absent grasp reflex.
Unable to roll from back to abdomen.
Exhibits head lag when pulled to a sitting position.
The Correct Answer is D
Choice A rationale:
Unable to hold a bottle is a developmental milestone expected at around 6 months of age. This is not a concerning finding for a 5-month-old infant.
Choice B rationale:
The grasp reflex is present in infants until about 6 months of age. Its absence is expected at 5 months and is not a cause for concern.
Choice C rationale:
Rolling from back to abdomen is typically achieved by 5 months of age. However, the inability to do so is not necessarily a red flag at this age, as each infant develops at their own pace.
Choice D rationale:
Head lag refers to the infant's head falling backward when pulled to a sitting position, indicating poor head control. This is a significant developmental red flag at 5 months of age and should be reported to the provider. It might indicate possible neuromuscular issues or developmental delays, requiring further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Stretch the perineum taut when applying the bag.
Choice A rationale:
Positioning the opening of the bag over both the urethra and the anus is incorrect because it increases the risk of contamination from fecal matter, which can lead to inaccurate test results.
Choice B rationale:
Stretching the perineum taut when applying the bag ensures a secure fit and reduces the risk of leakage, which is essential for accurate urine collection.
Choice C rationale:
Applying lidocaine gel to the perineum before attaching the bag is not recommended as it is unnecessary and could cause irritation or an allergic reaction in the infant.
Choice D rationale:
Placing a snug-fitting diaper over the drainage bag is not the correct action because it can cause the bag to become dislodged or compressed, leading to inaccurate collection or spillage.
Correct Answer is B
Explanation
Choice A rationale:
Contacting the client's parents for phone consent might breach the adolescent's confidentiality, especially if they are seeking STI testing. In many jurisdictions, adolescents have the right to confidential healthcare, including STI testing and treatment, without parental consent. Respecting the adolescent's autonomy and confidentiality is crucial in this situation.
Choice B rationale:
Obtaining written consent from the client, if they are of legal age (which is often 16 or older in many jurisdictions), is appropriate and respects the adolescent's autonomy and legal rights. Written consent ensures that the adolescent fully understands the tests being conducted and gives informed consent for the procedure.
Choice C rationale:
Requesting verbal consent from the social worker is not appropriate. Verbal consent can be ambiguous and may not provide sufficient legal documentation of informed consent, especially for sensitive procedures like STI testing.
Choice D rationale:
Postponing the testing until the client's parents are present might not be in the best interest of the adolescent, especially if they are seeking timely healthcare. Delays in testing and treatment could lead to complications or the spread of STIs. Respecting the adolescent's autonomy and providing appropriate, timely care is essential in this situation.
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