The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

The child does not vocally respond to voices.

The child never squeals or yells.

The child does not babble.

The child does not say dada or mama.

Answer and Explanation

The Correct Answer is C

A. The child does not vocally respond to voices: While vocal responsiveness is an important aspect of development, it may vary among infants and is not necessarily indicative of a developmental problem at 4 months.

B. The child never squeals or yells: Squealing and yelling are vocalizations that infants may or may not exhibit at this age, and their absence alone may not necessarily indicate a developmental problem.

C. The child does not babblE. Babbling, which typically begins around 4 to 6 months of age, involves the repetition of consonant-vowel combinations (e.g., "bababa"). The absence of babbling by 4 months may suggest a delay in language development and could be a potential sign of a developmental problem.

D. The child does not say dada or mamA. Infants may begin to associate "dada" or "mama" with specific caregivers, but this typically occurs later, closer to 6 to 9 months of age. The absence of this behavior at 4 months may not necessarily indicate a developmental problem.

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Correct Answer is B

Explanation

A. "Activity will increase the respiratory rate": While activity can indeed affect respiratory rate, counting for a full minute allows for a more accurate assessment of the newborn's baseline respiratory rate, regardless of activity level.

B. "The rate and rhythm of breath are irregular in newborns": This statement reflects an understanding of why a complete minute is necessary for counting the respiratory rate in newborns. Newborns often have irregular breathing patterns, so counting for a full minute helps ensure an accurate assessment of their respiratory rate.

C. "Newborns are abdominal breathers": While newborns primarily use their diaphragm to

breathe (abdominal breathing), this fact alone does not explain why the respiratory rate should be counted for a full minute.

D. "Newborns do not expand their lungs fully with each respiration": While newborns may not fully expand their lungs with each breath, this factor is not the primary reason for counting the respiratory rate for a full minute.

A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." B. "SIDS rates have been rising over the last 10 years." C. "Placing your child on her back when sleeping will decrease the risk of SIDS." D. "Sleep apnea is the main cause of SIDS."

Correct Answer is C

Explanation

A. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." - This

statement is incorrect. There is no direct correlation between vaccines and SIDS. In fact, research has shown that vaccines are not a cause of SIDS.

B. "SIDS rates have been rising over the last 10 years." - This statement is misleading. SIDS rates have actually been decreasing over the past few decades due to increased awareness and preventive measures.

C. "Placing your child on her back when sleeping will decrease the risk of SIDS." - This statement is accurate. Placing infants on their backs to sleep is one of the most effective

strategies for reducing the risk of SIDS, according to recommendations from pediatric health organizations.

D. "Sleep apnea is the main cause of SIDS." - This statement is incorrect. While sleep apnea is a sleep-related breathing disorder, it is not the main cause of SIDS. SIDS is a complex phenomenon with multiple contributing factors, but sleep position plays a significant role in reducing its risk.

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The nurse is assessing a 4-month-old boy during a scheduled visit. Which findings might suggest a developmental problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

Correct Answer is B

Explanation

A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

Correct Answer is C

Explanation

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