The nurse is completing an assessment on a 3-month-old male who is in the pediatrician’s office because the infant had a fever and diarrhea for the past 2 days. The infant’s history reveals his mother had preeclampsia and the child was delivered via emergency C-section prematurely at 30 weeks gestation. The nurse performs a history and assessment and finds the following. Which assessment findings require follow-up by the nurse? (Select all that apply)
Unable to roll over back to front
Head lag
Feeding difficulties
Floppy posture
Arms are stiff
Does not smile
Unable to sit without support
Irritable and cries often
Unable to pass an object between hands
Correct Answer : A,B,C,D,E,F,G,H,I
The correct answer is
A. Unable to roll over back to front
B. Head lag
C. Feeding difficulties
D. Floppy posture
E. Arms are stiff
F. Does not smile
G. Unable to sit without support
H. Irritable and cries often
I. Unable to pass an object between hands
Choice A reason
Unable to roll over back to front: At 3 months, infants typically start to develop the ability to roll over from their stomach to their back. Rolling over from back to front usually occurs later, around 4 to 6 months. However, the inability to roll over at all by 3 months could indicate developmental delays or muscle weakness, which requires follow-up.
Choice B Reason
Head lag: By 3 months, infants should have enough neck muscle strength to hold their head up when pulled to a sitting position. Persistent head lag at this age can be a sign of developmental delay or neuromuscular disorders, necessitating further evaluation.
Choice C Reason
Feeding difficulties: Infants should be able to suck and swallow effectively by 3 months. Feeding difficulties can lead to inadequate nutrition and growth, and may indicate underlying issues such as gastrointestinal problems or neurological disorders. This requires prompt attention and intervention.
Choice D Reason
Floppy posture: A 3-month-old should start to show more control over their body movements and have a more stable posture. Floppy posture, also known as hypotonia, can be a sign of various conditions, including genetic disorders, muscle diseases, or central nervous system issues. It is important to investigate the cause of hypotonia.
Choice E Reason
Arms are stiff: Stiffness in the arms, or hypertonia, can indicate neurological problems such as cerebral palsy or other motor disorders. It is crucial to assess the underlying cause of increased muscle tone and provide appropriate interventions.
Choice F Reason
Does not smile: Social smiling typically begins around 6 to 8 weeks of age. If a 3-month-old does not smile, it could be a sign of developmental delay, visual impairment, or other social and emotional issues. This warrants further assessment to determine the cause.
Choice G Reason
Unable to sit without support: While sitting without support is not expected until around 6 months, the inability to show any signs of trying to sit or maintain a sitting position with support at 3 months could indicate developmental delays. This should be monitored and addressed if necessary.
Choice H Reason
Irritable and cries often: Excessive irritability and frequent crying can be signs of discomfort, pain, or underlying medical conditions such as infections, gastrointestinal issues, or neurological problems. It is important to identify and address the cause of the infant’s distress.
Choice I Reason
Unable to pass an object between hands: By 3 months, infants should start to develop hand-eye coordination and the ability to grasp objects. The inability to pass an object between hands may indicate developmental delays or motor skill issues, which require further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Marbles are not a safe play activity for a 3-year-old in a spica cast. Marbles are small and can pose a choking hazard. Additionally, playing with marbles requires fine motor skills and movement that may be restricted by the cast.
Choice B Reason:
Watching a movie is a safe activity but does not provide developmental benefits. While it can keep the child entertained, it does not engage the child in active play or promote cognitive and motor development.
Choice C Reason:
A game of checkers may be too advanced for a 3-year-old. It requires understanding of rules and strategic thinking, which may be beyond the developmental stage of a child this age. Additionally, it may not be engaging enough to hold the child’s attention.
Choice D Reason:
Playing with a toy telephone is an appropriate activity for a 3-year-old in a spica cast. It is safe and can be done while the child is in a stationary position. This activity encourages imaginative play and can help with language development and social skills.
Correct Answer is A
Explanation
Choice A reason:
Cleansing the suture line, maintaining an upright position, and using arm restraints are crucial aspects of postoperative care for an infant after cleft lip repair. Cleansing the suture line helps prevent infection and promotes healing. Keeping the infant in an upright position reduces the risk of aspiration and helps with breathing. Arm restraints prevent the infant from touching or rubbing the surgical site, which could disrupt the healing process.
Choice B Reason:
Mouth irrigations and a prone position are not recommended for postoperative care after cleft lip repair. Mouth irrigations can be too harsh for the delicate surgical site, and a prone position (lying face down) can increase the risk of aspiration and breathing difficulties. Cleansing the suture line is important, but the other aspects of this choice are not suitable.
Choice C Reason:
Frequent oral suction and spoon feeding are not appropriate for an infant after cleft lip repair. Oral suction can be too aggressive and may damage the surgical site. Spoon feeding is not recommended as it can put pressure on the healing lip. Giving a teething toy is also not advisable as it can cause the infant to put objects in their mouth, potentially harming the surgical site.
Choice D Reason:
Arm restraints are indeed necessary to prevent the infant from touching the surgical site. However, postural drainage and mouth irrigations are not suitable for postoperative care after cleft lip repair. Postural drainage is not relevant to this condition, and mouth irrigations can be too harsh for the healing tissue.
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