The nurse is assessing the neurological system of a 1-month-old infant. During the exam, the infant demonstrates an absence of the startle (Moro) reflex.
Which intervention should the nurse implement first?
Assess the infant's response to auditory stimuli.
Notify the healthcare provider of the findings.
Document the findings in the electronic medical record.
Tell the mother that the infant needs a further assessment.
The Correct Answer is B
Choice A rationale
Assessing the infant's response to auditory stimuli is a component of a comprehensive neurological examination. However, the absence of a primitive reflex, such as the Moro reflex, which should be present at this age, is a significant abnormal finding indicative of a potential neurological deficit. Therefore, this action is a secondary step after addressing the primary concern.
Choice B rationale
The absence of the Moro reflex in a 1-month-old infant is a critical finding that suggests a potential neurological impairment, possibly affecting the central nervous system or musculoskeletal system. Normal Moro reflex should be present from birth until around 3 to 4 months of age. Prompt notification of the healthcare provider is necessary to ensure a timely and thorough evaluation of the infant's neurological status.
Choice C rationale
Documentation is a crucial part of nursing practice, but it is not the first intervention. The nurse must first act on the abnormal finding to ensure the safety and well-being of the infant. The priority is to communicate the significant assessment finding to the healthcare provider so a plan of care can be established.
Choice D rationale
While patient education is important, simply telling the mother that a further assessment is needed does not constitute a primary intervention. The nurse's immediate responsibility is to address the clinical finding with the medical team. The healthcare provider will then order the necessary diagnostic tests and treatments, and the nurse can provide education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Using one-word sentences is a developmental milestone typically seen in infants around 12 to 18 months of age. A 3-year-old child should have significantly more advanced language skills. This language pattern would indicate a developmental delay and require further investigation.
Choice B rationale
The use of gestures with one to two-word sentences is a skill observed in toddlers between 18 and 24 months. By 3 years of age, a child's vocabulary has expanded significantly, and they are capable of forming longer, more complex sentences. This skill level is not appropriate for a 3-year-old.
Choice C rationale
A 3-year-old child's language skills are well-developed. They typically use simple sentences with four or more words, can ask "what" and "who" questions, and their speech is generally understandable to familiar listeners. This milestone reflects normal cognitive and linguistic development for this age group.
Choice D rationale
Recognizing most letters and numbers is a developmental milestone that typically emerges around 4 to 5 years of age, during the preschool period. While some 3-year-olds may recognize a few letters, this is not a normal or expected skill for their age. It is a more advanced skill.
Correct Answer is D
Explanation
Choice A rationale
The direction and volume of blood flow through a VSD depend on the size of the defect and the pressure difference between the ventricles. A small VSD typically has a left-to-right shunt due to higher systemic pressure. This flow pattern does not typically cause valvular dysfunction, but rather increases pulmonary blood flow.
Choice B rationale
Small VSDs often do not require surgical intervention because they are hemodynamically insignificant and may close on their own. Surgical repair is generally reserved for large, symptomatic VSDs that cause congestive heart failure, pulmonary hypertension, or failure to thrive.
Choice C rationale
The prognosis following surgical repair of a VSD is generally excellent, with a low mortality rate. The outcome is highly dependent on the child's preoperative status, and most children have normal lives after successful repair.
Choice D rationale
Spontaneous closure of small muscular VSDs is a well-documented phenomenon. The closure is often attributed to muscular trabeculae growth and the formation of fibrous tissue around the defect. The likelihood of closure decreases with age.
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