A nurse is caring for an infant in the provider's office.
Drag words from the choices below to fill in each blank in the following sentence.
The nurse identifies the assessment findings of
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Developmental milestones are used to evaluate neurological, motor, and social progression during infancy. At 9 months of age, infants are expected to sit independently, begin pulling to stand, and demonstrate early language development such as babbling. Failure to achieve age-appropriate gross motor and language milestones may indicate developmental delay, neurological impairment, or underlying systemic conditions requiring further evaluation.
Rationale for correct choices:
• Sitting ability: By 9 months, infants are expected to sit independently without trunk support and begin transitioning toward crawling and pulling to stand. This infant is only able to sit with trunk support, which indicates delayed gross motor development. This suggests possible neuromuscular delay, hypotonia, or other developmental concerns affecting core muscle strength and postural control. Delayed sitting ability should be reported for further evaluation.
• Vocalization: By 6 to 9 months of age, infants should be babbling with consonant sounds such as “ba,” “da,” or “ma,” which reflects normal language and social development. The absence of vocalization or babbling at 9 months is a significant developmental delay in speech and language milestones. This may indicate hearing impairment, neurological delay, or global developmental delay. Lack of early communication skills requires further assessment.
Rationale for incorrect choices:
• Tooth eruption: The appearance of a single lower central incisor at 6 months falls within normal variation and does not require concern. Tooth eruption timing differs significantly between infants and is not used as a primary developmental milestone marker. Therefore, this finding is considered normal and does not need to be reported.
• Fine motor skills: No evidence in the assessment suggests abnormal fine motor development, such as inability to grasp objects or poor hand coordination. Without abnormal findings, fine motor skills cannot be identified as delayed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Postoperative care following a tonsillectomy requires close monitoring for hemorrhage, which is one of the most serious complications in children. Early signs of bleeding may be subtle and include frequent throat clearing, swallowing, restlessness, or changes in behavior before visible blood is seen. Because the surgical site is highly vascular, prompt assessment is essential when any concerning symptom arises. Nursing priorities focus on airway safety, early detection of bleeding, and prevention of aspiration.
Rationale:
A. Giving the child small sips of water is not the priority because oral intake may worsen bleeding or trigger swallowing of blood if hemorrhage is present. Fluids are usually introduced only after assessment confirms no active bleeding. Immediate assessment should occur before encouraging oral intake.
B. Administering an analgesic is important for comfort but is not the first action when bleeding is suspected. Pain control should not take priority over evaluating a potential postoperative hemorrhage. Addressing safety concerns such as bleeding risk must come first before symptom relief.
C. Observing the child’s throat with a flashlight is the correct first action because frequent throat clearing may indicate bleeding at the surgical site. Direct visualization helps determine if there is active hemorrhage or clot disruption. Early identification of bleeding is critical to prevent airway compromise and allow immediate intervention.
D. Offering an ice collar may help reduce swelling and provide comfort but does not address the priority concern of possible bleeding. Supportive measures like cold therapy are appropriate only after assessment rules out complications. Safety assessment must always precede comfort interventions in this situation.
Correct Answer is ["B","C","D","E"]
Explanation
The clinical presentation of a 7-month-old with a paroxysmal cough, thick mucus, and wheezing is highly suggestive of bronchiolitis, most commonly caused by Respiratory Syncytial Virus (RSV). In infants, respiratory distress can progress rapidly due to their small airways and high metabolic demands. Worsening condition is identified by an increase in work of breathing (WOB), rising compensatory heart and respiratory rates, and a declining ability to maintain oxygenation despite the introduction of supplemental oxygen.
Rationale for worsening findings:
• Bilateral wheezes on inspiration and expiration: Previously, wheezing was noted only on auscultation, but now it is present throughout both inspiration and expiration, indicating increased airway narrowing. This suggests progression of bronchiolar inflammation and obstruction. Biphasic wheezing is a sign of worsening airflow limitation.
• Moderate substernal, subcostal, and intercostal retractions: Increasing retractions indicate that the infant is using accessory muscles more intensely to maintain ventilation. Progression from mild to moderate retractions reflects worsening airway obstruction and increased respiratory effort. This suggests fatigue and declining respiratory efficiency.
• Respiratory rate 54/min: An increasing respiratory rate indicates worsening respiratory distress and decreased oxygen exchange efficiency. Infants compensate for hypoxia by breathing faster, but persistent tachypnea suggests fatigue and impending respiratory failure. The rise from 48/min to 54/min demonstrates progression of illness severity.
• Oxygen saturation 95% on 2 L oxygen via nasal cannula: A decreasing oxygen saturation despite supplemental oxygen indicates worsening gas exchange. The need for oxygen therapy itself reflects progression from mild to moderate respiratory compromise. A drop from 97% on room air to 95% on oxygen shows reduced respiratory efficiency.
Rationale for incorrect findings:
• Mucous membranes are pink for ethnic background: This finding remains consistent with adequate oxygenation and perfusion. There is no progression to pallor or cyanosis, which would indicate worsening hypoxia. Stability in mucous membrane color suggests that oxygen delivery is still being maintained. Therefore, this is not an indicator of clinical decline.
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