A nurse is collecting data from a 9-month-old infant.

Which of the following findings requires a nursing intervention?

Positive Moro reflex.

Negative Doll's eye reflex.

Positive Babinski reflex.

Negative Crawl reflex.

Answer and Explanation

The Correct Answer is A

The correct answer is a. Positive Moro reflex.

Choice A reason:

Positive Moro reflex: This reflex should disappear by 6 months of age. Its presence at 9 months indicates potential neurological issues.

Choice B reason:

Negative Doll’s eye reflex: This reflex, indicating brainstem function, should be positive in infants. A negative result suggests severe brainstem dysfunction

Choice C reason:

Positive Babinski reflex: This reflex is normal up to 2 years of age. It indicates normal neurological development in infants.

Choice D reason:

Negative Crawl reflex: Crawling typically develops between 6-10 months. A negative crawl reflex at 9 months could indicate developmental delays

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Correct Answer is A

Explanation

A client who has a blood pressure of 140/90 mm Hg. Hypertension is a contraindication to oral contraceptives.
Choice B is incorrect because having a menstrual cycle every 14 days is not a contraindication to oral contraceptives.
Choice C is incorrect because having a hematocrit of 39% is not a contraindication to oral contraceptives.
Choice D is incorrect because being 15 years old and having acne is not a contraindication to oral contraceptives.

A. Continue to monitor for another hour. B. Administer an antipyretic. C. Assist the client in ambulation. D. Notify the RN; she will notify the provider.

Correct Answer is D

Explanation

A postpartum fever is defined as a temperature greater than 100.4 degrees F (38.0 degrees C) on at least two occasions.
These fevers cannot be ignored as they can represent serious infections. The first task is to identify the source.
Choice A is not correct because continuing to monitor for another hour may delay necessary treatment.
Choice B is not correct because administering an antipyretic may only treat the symptom and not address the underlying cause of the fever.
Choice C is not correct because assisting the client in ambulation does not address the underlying cause of the fever.

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A nurse is collecting data from a 9-month-old infant. Which of the following findings requires a nursing intervention?

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Naxlex Comprehensive Predictor Exams

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A nurse is collecting data from a 9-month-old infant.

Which of the following findings requires a nursing intervention?