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 A
Explanation
A. Lansoprazole is a proton pump inhibitor (PPI) that is most effective when taken 30 minutes before meals, as it works by reducing stomach acid production in response to food intake.
B. Lansoprazole capsules should not be placed under the tongue, as they are intended to be swallowed whole to ensure proper absorption.
C. Lansoprazole is typically prescribed once daily, not four times per day, unless otherwise directed by the healthcare provider.
D. Chewing the capsule would interfere with its controlled-release formulation, leading to reduced effectiveness. The capsule should be swallowed whole.
Correct Answer is B
Explanation
A. Crushing sustained-release tablets is not recommended because it can alter the medication's intended effect, releasing it all at once, which can be dangerous for the child.
B. Allowing medications to flow into the tube by gravity is the correct method. It ensures the medication is delivered slowly and effectively, preventing the tube from clogging and ensuring proper absorption.
C. Flushing the tube with 2 mL of sterile water is insufficient after all medications are administered. Typically, the tube should be flushed with 15-30 mL of water before and after medication administration to ensure patency.
D. Mixing all medications together is not recommended because different medications may have incompatible properties, and mixing them could alter their effectiveness or cause adverse reactions. Each medication should be administered separately.
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