A nurse is collecting data on a 1-month-old infant during a well-child visit. Which of the following findings should the nurse expect?
Absent rooting reflex
Respiratory rate 64/min
Head lag
Yellow sclera
The Correct Answer is B
A. The rooting reflex should be present at 1 month of age, not absent. This reflex is triggered when the infant’s cheek is stroked, prompting the baby to turn their head toward the stimulus and open their mouth.
B. A respiratory rate of 64/min is within the expected range for a 1-month-old infant, whose normal respiratory rate is typically between 30–60 breaths per minute.
C. Head lag is normal at 1 month of age when the infant's head is lifted while they are in a sitting position. However, by 4 months of age, the infant should have more head control and reduced head lag.
D. Yellow sclera indicates jaundice, which is common in newborns but should be assessed if present at 1 month to ensure it resolves. By this time, any jaundice should be resolving or gone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Repositioning the pulse oximetry probe every 2 hours is unnecessary unless there is a concern about skin integrity or the accuracy of the reading. Continuous monitoring generally requires the probe to be in place for longer periods.
B. Taping the wire to the palm of the hand is not recommended because it may cause skin irritation or pressure injury. The sensor should be placed on a finger or toe, where blood flow is easily accessible.
C. Applying the sensor to the index fingernail is not ideal. Pulse oximetry is most accurate when applied to a finger or toe, but not directly on the nail itself. It should be placed on the skin near the nail.
D. Warming the skin prior to probe placement is recommended to ensure better circulation and accurate pulse oximetry readings, especially in children or individuals with poor peripheral circulation.
Correct Answer is D
Explanation
A. While it is important to maintain confidentiality, the nurse must follow mandatory reporting laws for suspected abuse, which may require informing appropriate authorities.
B. While it may be important to acknowledge the harm done, directly labeling the parent's behavior as "wrong" could potentially escalate the situation and may not be helpful in building rapport with the adolescent.
C. Making assumptions about the behavior of another parent can be seen as judgmental and may not be helpful in addressing the adolescent’s concerns or in facilitating a safe environment for disclosure.
D. This response provides reassurance to the adolescent that they are not responsible for the abuse and helps to create a nonjudgmental, supportive environment, allowing the adolescent to feel safe and heard.
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