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 A
Explanation
Answer is A. Use a 24-gauge catheter to start the IV.
A 24-gauge catheter is the smallest and most appropriate size for an infant's vein¹. It reduces the risk of infiltration, phlebitis, and thrombosis².
B. Start the IV in the infant's foot. Statement is wrong because starting the IV in the foot can interfere with the infant's mobility and increase the risk of infection³. The preferred sites for IV insertion in infants are the scalp, hand, or arm veins⁴.
C. Change the IV site every 3 days. Statement is wrong because changing the IV site every 3 days is not recommended for infants and children. The IV site should be changed only when clinically indicated, such as signs of infection, infiltration, or phlebitis.
D. Cover the insertion site with an opaque dressing. Statement is wrong because covering the insertion site with an opaque dressing can obscure the visibility of the site and prevent early detection of complications. A transparent dressing is preferred as it allows for continuous assessment of the site.
Correct Answer is C
Explanation
Choice A rationale:
Limiting fluids at bedtime is not a suitable instruction for a child with sickle cell disease. These patients are at risk of dehydration due to increased red blood cell destruction, and limiting fluids can exacerbate this condition, leading to vaso-occlusive crises and pain episodes.
Choice B rationale:
Applying cold compresses to painful areas might provide temporary relief for pain associated with sickle cell disease, but it does not address the overall management of the illness. Encouraging physical activity, on the other hand, is essential as it promotes overall health and can prevent complications like thrombosis.
Choice C rationale:
Encouraging physical activity as tolerated is the correct choice. Regular physical activity helps improve circulation and can reduce the risk of vaso-occlusive crises in patients with sickle cell disease. The nurse should advise the guardians to encourage the child to engage in activities that are appropriate for their age and physical condition, while also being mindful of any signs of fatigue or pain.
Choice D rationale:
Having the child wear a surgical mask to school is not relevant to the management of sickle cell disease. This measure is more appropriate for preventing the spread of contagious diseases and is not a specific intervention for sickle cell disease management.
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