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 C
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 C
Explanation
A. Removing outer clothing can be uncomfortable or distressing for toddlers, so it is often better to do this gradually, allowing the child to feel more at ease.
B. Allowing the toddler to sit in the parent's lap can provide comfort and security during the examination.
C. Allowing the toddler to inspect the stethoscope is an effective way to reduce anxiety and establish trust with the child.
D. Traumatic procedures, such as immunizations or blood draws, should be done last to avoid causing unnecessary distress during the examination.
Correct Answer is A
Explanation
A. This response reassures the child that they are not to blame for the abuse and provides emotional support. It also establishes a sense of safety for the child to express their feelings.
B. Telling the child that they should have spoken up earlier may cause shame or guilt, which can further harm the child’s emotional well-being.
C. Promising not to tell anyone would be unethical because it is necessary to report suspected abuse to the appropriate authorities for the child's safety.
D. While this response acknowledges the injustice of the situation, it doesn't validate the child's feelings of fear or confusion in a way that encourages trust and healing.
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