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
Choice A rationale:
Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.
Choice B rationale:
Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.
Choice C rationale:
Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.
Choice D rationale:
Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly. Please note that questions 73 and 74 could not be answered accurately due to the lack of specific options and context provided. If you can provide the options for these questions, I would be happy to assist you further.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Partial thromboplastin time (PTT) measures the time it takes for blood to clot and is used to monitor conditions like bleeding disorders or the effectiveness of anticoagulant therapy. PTT is not specific to rheumatic fever and does not contribute to confirming this diagnosis.
Choice B rationale:
Blood urea nitrogen (BUN) measures the amount of nitrogen in the blood that comes from urea. It is a marker of kidney function and hydration status. BUN levels are not directly related to rheumatic fever and do not play a role in confirming this diagnosis.
Choice C rationale:
Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation in the body. Elevated ESR levels indicate the presence of inflammation but do not confirm a specific diagnosis. In the context of suspected rheumatic fever, elevated ESR levels, along with other clinical findings, can support the diagnosis.
Choice D rationale:
Antistreptolysin O (ASO) titer measures the level of antibodies against streptolysin O, a toxin produced by group A Streptococcus bacteria. Elevated ASO titers indicate a recent streptococcal infection, which is a common trigger for rheumatic fever. Positive ASO titers, along with clinical symptoms and other laboratory findings, contribute to confirming the diagnosis of rheumatic fever.
Choice E rationale:
C-reactive protein (CRP) is another marker of inflammation in the body. Elevated CRP levels indicate the presence of inflammation but do not confirm a specific diagnosis. In the context of suspected rheumatic fever, elevated CRP levels, along with other clinical and laboratory findings, can support the diagnosis by indicating the presence of inflammation.
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