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. There is no need to notify the provider if urine output is within the normal range.

B. Oral rehydration may not be necessary if the child is adequately hydrated.

C. A bladder scan is not required if the urine output is within the normal range.

D. Continue to monitor the client as the urine output is within the normal range. For a 3-year-old child (15 kg), normal urine output is 1-2 mL/kg/hr. This child’s output is approximately 1.3 mL/kg/hr, which is normal.

A. “I've wondered why my child won't let me in the room when changing clothes." B. "My child has such a hard time finding pants that fit right. They never seem to fit evenly over the hips." C. "My child has been reporting back pain for the last 2 or 3 months." D. "My child has been taking ibuprofen daily for the last few weeks because of hip pain after walking so much at school."

Correct Answer is B

Explanation

A. The child’s reluctance to change clothes in front of others might suggest body image issues, but it doesn’t directly indicate spinal curvature.

B. Difficulty finding pants that fit evenly over the hips could indicate a scoliosis-related curvature, where one hip may be higher than the other.

C. Back pain could be related to various conditions, including scoliosis, but by itself, it’s not definitive for spinal curvature.

D. Daily use of ibuprofen for hip pain may indicate musculoskeletal issues but doesn’t directly relate to spinal curvature or scoliosis.

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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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