During a routine assessment of an 8-month-old, the nurse is assessing primitive reflexes. Which finding should the nurse expect for an infant of this age?

When hearing a loud noise, the infant cries and extends both arms and legs.

When stroking the outer edge of the sole of the infant's foot, the toes fan upward and out.

When infant's head is turned to one side, extension of the same side arm and leg occurs.

When stroking the cheek, the infant turns toward that side of stimulation.

Answer and Explanation

The Correct Answer is B

A. The Moro reflex, where the infant cries and extends both arms and legs in response to a loud noise, typically disappears by 4-6 months of age and would not be expected at 8 months.

B. The Babinski reflex, where the toes fan upward and out when the outer edge of the sole is stroked, is normal in infants and usually disappears by 12-24 months of age.

C. The tonic neck reflex (fencing reflex) typically disappears around 4-6 months of age, so it would not be expected in an 8-month-old.

D. The rooting reflex, where the infant turns their head toward the side of stimulation when the cheek is stroked, typically disappears by 3-4 months of age.

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Correct Answer is D

Explanation

A. Urinary and bowel continence is expected by age 4, so this does not warrant further investigation.

B. Tying shoes is a skill typically developed later, around 5-6 years of age, so not being able to do so at age 4 is not concerning.

C. Having an imaginary friend is common in children around this age and is not a cause for concern.

D. Speaking in 2-3 word sentences is typical for a younger child, around 2 years of age. By age 4, a child should be able to speak in more complex sentences, so this finding warrants further investigation.

A. Tender inguinal lymph nodes B. Enlarged liver C. Protuberant abdomen D. Periorbital edema

Correct Answer is C

Explanation

A. Tender inguinal lymph nodes are not associated with celiac disease and are more indicative of localized infections or lymphadenopathy.

B. An enlarged liver is not typically related to celiac disease but may occur in other conditions such as fatty liver disease.

C. A protuberant abdomen is a common finding in children with celiac disease due to malabsorption and gas accumulation in the intestines. This is often accompanied by abdominal distension and discomfort.

D. Periorbital edema is not characteristic of celiac disease and is more commonly seen in conditions like nephrotic syndrome.

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During a routine assessment of an 8-month-old, the nurse is assessing primitive reflexes. Which finding should the nurse expect for an infant of this age?

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