The nurse is assessing the neuromusculoskeletal system of a newborn. What is an abnormal assessment finding?
Absence of hypotonia
Full range of motion in extremities
Sluggish deep tendon reflexes
Lack of eye muscle control resulting in "wandering eyes"
The Correct Answer is C
A. Newborns typically exhibit a degree of physiological hypotonia, meaning their muscles are naturally a bit “floppy” due to immature neuromuscular development. Hypotonia in this context is expected and normal; therefore, the absence of hypotonia (meaning the baby has normal or increased muscle tone) is not abnormal. It suggests that muscle tone is within expected limits and does not indicate pathology.
B. A normal newborn should have full and symmetric passive range of motion in all joints without resistance or stiffness. This finding indicates that the musculoskeletal system is developing appropriately. Limitations in movement, joint contractures, or asymmetry would be considered abnormal, but full range of motion is normal.
C. Deep tendon reflexes in a newborn are expected to be brisk or moderately active due to the immature but intact nervous system. Sluggish or absent reflexes can indicate several potential problems: Peripheral nervous system dysfunction, such as peripheral neuropathy or spinal cord injury. Central nervous system abnormalities, including hypoxic-ischemic encephalopathy, brain or spinal cord malformations, or developmental delays. Metabolic or systemic disorders, such as hypothyroidism or electrolyte imbalances, which can affect neuromuscular function. Sluggish reflexes are therefore an abnormal finding and warrant further evaluation.
D. Mild eye wandering in newborns is common and considered a normal part of ocular development. At birth, infants’ eye muscles are not fully coordinated, so they may appear crossed or wander intermittently. This usually resolves by 3–4 months of age as visual tracking and extraocular muscle control mature. Persistent or severe strabismus later than 4–6 months would be abnormal, but in the immediate newborn period, this is typical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Traction weights are prescribed by the healthcare provider and should not be adjusted by the nurse unless specifically ordered. Changing weights without an order can compromise fracture alignment or cause injury.
B. Proper traction requires constant, uninterrupted force to maintain fracture alignment. Weights must hang freely to provide the correct pull; if they touch the bed or floor, traction effectiveness is lost, potentially delaying healing or causing malalignment. This is a fundamental aspect of safe traction care.
C. Traction weights are continuous unless ordered to be temporarily released for specific procedures. Routine removal disrupts the therapeutic force and can interfere with fracture healing or cause complications.
D. Traction management is a licensed nursing responsibility, especially when it involves weights and maintaining proper alignment. UAPs can assist with positioning or hygiene, but they should not remove weights, and ambulation is generally restricted depending on fracture type and traction method.
Correct Answer is A
Explanation
A. School-aged children (ages 6–12) require adequate complex carbohydrates and fiber for energy, growth, and gastrointestinal health. Whole grains and enriched cereals provide essential vitamins (e.g., B vitamins, iron) and fiber, supporting proper growth, digestion, and cognitive function. This advice aligns with USDA Dietary Guidelines and promotes balanced nutrition in children.
B. Protein is essential for growth, muscle development, and tissue repair in school-aged children. Limiting it to one meal per day could lead to inadequate intake of essential amino acids and impair growth. Children should consume age-appropriate amounts of protein distributed across meals.
C. Milk is an important source of calcium, vitamin D, and protein, critical for bone development and growth during late childhood. Limiting milk unnecessarily could increase the risk of calcium deficiency and poor bone mineralization. Recommendations typically allow 2–3 servings of dairy per day.
D. While vegetables are important, school-aged children should consume a variety of vegetables daily, not just twice a week. Dark green leafy vegetables provide vitamins A, C, K, folate, and iron, which are crucial for overall health, immune function, and growth. Limiting consumption to twice a week is insufficient.
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