A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse not report to the provider?
The infant does not exhibit fear of strangers.
The infant does not roll over from his abdomen to his back.
The infant does not pick up objects from the floor with his fingers.
The infant does not sit on the floor unsupported.
None
None
The Correct Answer is A
A. The infant does not exhibit fear of strangers.
The infant does not exhibit fear of strangers is not a finding that the nurse should report to the provider, as this is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.
B. The infant does not roll over from his abdomen to his back.
By 6 months of age, most infants can roll over in both directions— from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.
C. The infant does not pick up objects from the floor with his fingers.
By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.
D. The infant does not sit on the floor unsupported.
By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Visual acuity 20/30 bilaterally: Visual acuity of 20/30 bilaterally indicates relatively good vision in both eyes, but it does not necessarily indicate strabismus. Strabismus is related to eye alignment rather than visual acuity.
B. Peripheral vision 70° downward: Peripheral vision refers to the ability to see objects outside the direct line of vision. While changes in peripheral vision can occur in various eye conditions, such as glaucoma, it is not specific to strabismus.
C. Movement of the uncovered eye during a cover test: This is the correct option. During a cover test, one eye is covered while the other eye fixates on an object. If the uncovered eye moves to try to align with the covered eye, it may indicate strabismus or a misalignment of the eyes.
D. Light reflects symmetrically within each pupil during a corneal light reflex test: A corneal light reflex test assesses the alignment of the eyes by observing the reflection of light on the corneas. While asymmetry in the corneal light reflex can indicate strabismus, the description provided in this option suggests that the light reflects symmetrically within each pupil, which is a normal finding.
Correct Answer is A
Explanation
A. Droplet:
Pertussis is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve placing the child in a private room or with another child with the same infection. Healthcare workers should wear a mask or respirator when entering the room to protect against droplet transmission.
B. Contact:
Contact precautions are used for infections that can be spread by direct or indirect contact with the patient or their environment. Pertussis is not typically spread through contact with contaminated surfaces or objects.
C. Airborne:
Airborne precautions are used for infections that are transmitted through small droplet nuclei that remain in the air for long periods. Pertussis is primarily transmitted through larger respiratory droplets rather than tiny airborne particles.
D. Protective environment:
Protective environment precautions are used for patients who have weakened immune systems, such as those undergoing bone marrow transplants. These precautions are not applicable for a child with pertussis.
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