A nurse is instructing a newly licensed nurse on how to conduct head and neck assessments in pediatric patients. Which statement by the newly licensed nurse indicates a correct understanding of the assessment process?
"An infant's lymph nodes may be large and tender at 2 months of age."
"Infants should be able to hold their head steady without support by 3 months of age."
"Facial drooping during assessment is a normal finding and does not require further action."
"Inspection and palpation should be used to evaluate the skull, eyes, ears, nose, mouth, throat, and neck structures."
The Correct Answer is D
A. "An infant's lymph nodes may be large and tender at 2 months of age.": While lymph nodes can be slightly enlarged in infants, tenderness or significant enlargement at 2 months may indicate infection or another underlying condition and is not considered a normal finding.
B. "Infants should be able to hold their head steady without support by 3 months of age.": Most infants develop good head control by 4 months, not 3 months. Expecting full head steadiness at 3 months is premature and reflects misunderstanding of typical developmental milestones.
C. "Facial drooping during assessment is a normal finding and does not require further action.": Facial drooping is abnormal at any age and may indicate neurologic compromise, such as cranial nerve VII palsy. It warrants immediate evaluation rather than being considered normal.
D. "Inspection and palpation should be used to evaluate the skull, eyes, ears, nose, mouth, throat, and neck structures.": This statement correctly describes the comprehensive approach to pediatric head and neck assessment. Both inspection and palpation are essential for identifying abnormalities in structure, symmetry, and function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Sucking reflex: The sucking reflex requires the newborn to be awake and alert to coordinate sucking motions, so it cannot be reliably assessed while the infant is asleep.
B. Rooting reflex: The rooting reflex also requires the newborn to be awake and responsive, as it depends on the infant turning the head toward a tactile stimulus near the mouth.
C. Plantar grasp reflex (Babinski): The plantar grasp reflex can be assessed even when the newborn is asleep, as it involves applying gentle pressure to the sole of the foot, causing toe flexion. It is a reliable indicator of neurological integrity in the sleeping state.
D. Moro (startle) reflex: The Moro reflex requires the infant to be awake and responsive to sudden stimuli or a gentle drop sensation, making it unsuitable for assessment during sleep.
Correct Answer is A
Explanation
A. "It is caused primarily by a combination of genetic factors and maternal environmental exposures during early pregnancy, such as smoking, certain medications, and infections.": Cleft lip results from incomplete fusion of the maxillary and medial nasal processes during early embryonic development,. Both genetic predisposition and environmental exposures, including maternal smoking, alcohol use, certain medications and infections, increase the risk.
B. "A cleft lip is due to an abnormal autoimmune response.": Autoimmune responses are not considered a primary cause of cleft lip. The defect occurs during early facial development, not as a result of immune-mediated processes.
C. "Intrauterine hypoxia causing tissue necrosis of the lip during the third trimester.": Tissue necrosis in the third trimester cannot cause a cleft lip, as the structural fusion occurs much earlier in embryogenesis.
D. "Postnatal trauma to the upper lip during delivery.": Cleft lip is a congenital malformation present at birth, not a result of trauma during delivery. Postnatal injury cannot create this congenital defect.
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