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.
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Related Questions
Correct Answer is D
Explanation
A. While prolonged exposure to peanuts may increase the risk of severe reactions, the severity of the allergy doesn't necessarily worsen due to exposure.
B. The child is only allergic to peanuts, not all types of nuts. Therefore, they may be able to safely eat other nuts, but they must avoid peanuts specifically.
C. Many children outgrow certain food allergies, but peanut allergies tend to persist into adulthood, making it less likely that the child will outgrow it by adolescence.
D. Epinephrine is the first-line treatment for a severe allergic reaction, and carrying an epinephrine auto-injector is essential for managing anaphylaxis quickly if it occurs.
Correct Answer is A
Explanation
A. The new onset of lethargy in a child with endocarditis is a significant concern, as it can indicate worsening infection or complications such as embolism. This child requires urgent assessment to prevent further deterioration.
B. Erythema of the lips in a child with Kawasaki disease is concerning, but this symptom is expected as part of the disease process. However, other signs like fever and conjunctivitis would be more concerning.
C. An increased erythrocyte sedimentation rate (ESR) in a child with rheumatic fever suggests inflammation, but it is not an immediate life-threatening concern like the lethargy in endocarditis.
D. Weak pedal pulses in a toddler with coarctation of the aorta indicate circulatory compromise, but this child may not be in immediate danger as the condition is often diagnosed and managed with interventions like surgery or medication.
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