A nurse is teaching a group of parents about expected gross motor skills for infants. Which of the following skills should the nurse include for a 2- month-old infant?
Lifts head 45° when lying prone
Rolls over from back to abdomen
No head lag when pulled into a sitting position
Rolls over from abdomen to back
The Correct Answer is A
A. "Lifts head 45° when lying prone." By 2 months of age, infants begin lifting their heads about 45 degrees while on their stomachs, which is an early sign of developing neck and upper body strength.
B. "Rolls over from back to abdomen." Rolling from back to abdomen typically occurs around 6 months of age.
C. "No head lag when pulled into a sitting position." Head lag is still present at 2 months, but it gradually disappears by 4 months as neck muscles strengthen.
D. "Rolls over from abdomen to back." Rolling from abdomen to back typically occurs around 4 months of age, followed by rolling from back to abdomen at about 6 months.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Wear a face mask when working within 3 feet of a child who is infected." Influenza spreads through droplets, so wearing a face mask within 3 feet of an infected child helps prevent transmission.
B. "Administer antibacterial medication within 24 hr of the onset of symptoms." Influenza is caused by a virus, not bacteria, so antibacterial medications (antibiotics) are not effective. Antiviral medications (e.g., oseltamivir) may be given within 48 hours of symptom onset.
C. "Children should be considered infectious for 14 days after the onset of symptoms." . Children with influenza are most contagious 1 day before symptoms appear and up to 5 to 7 days after onset.
D. "Administer the influenza vaccine every 6 months." The influenza vaccine is given annually (once per year), not every 6 months.
Correct Answer is D
Explanation
A. "Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.
C. "Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).
D. "Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.
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