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 ["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.
Correct Answer is B
Explanation
The correct answer is choiceb. “We will place the diaper under the straps.”
Choice A rationale:
Adjusting the straps daily is not recommended.The straps should only be adjusted by a healthcare professional to ensure proper fit and effectiveness.
Choice B rationale:
Placing the diaper under the straps is correct.This helps to keep the harness clean and dry, and ensures that the straps remain in the correct position.
Choice C rationale:
The duration of wearing the Pavlik harness is typically longer than 2 weeks.It is usually worn for about 6-12 weeks, depending on the doctor’s recommendation.
Choice D rationale:
Applying lotion to the skin under the straps is not advised as it can cause skin irritation and affect the fit of the harness.
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