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 C
Explanation
Choice A reason:
Measuring the abdominal girth is a useful assessment tool in cases of suspected abdominal distension or fluid accumulation. However, in the context of intussusception, the passage of a currant jelly-like stool is a more critical indicator of the condition. While measuring abdominal girth can provide additional information, it is not the most appropriate immediate action in this scenario.
Choice B reason:
Notifying the practitioner as this is not a typical finding is incorrect because the passage of currant jelly-like stool is a classic symptom of intussusception. This stool appearance results from a mixture of mucus and blood due to the telescoping of the intestine, which compromises blood flow and causes ischemia. Therefore, this finding should be documented as expected rather than considered atypical.
Choice C reason:
Documenting the passage of currant jelly-like stool as an expected finding and planning to move forward with the procedure is the most appropriate action. This stool appearance is a hallmark sign of intussusception, indicating that the condition is present and needs to be addressed promptly. The radiologist-guided pneumoenema is a diagnostic and therapeutic procedure that can help resolve the intussusception by using air pressure to unfold the telescoped segment of the intestine. Therefore, documenting this finding and proceeding with the planned intervention is crucial.
Choice D reason:
Auscultating for bowel sounds is a standard nursing assessment technique to evaluate gastrointestinal function. However, in the context of intussusception, the passage of currant jelly-like stool is a more definitive indicator of the condition. While auscultating for bowel sounds can provide additional information about bowel activity, it is not the most appropriate immediate action in this scenario.
Correct Answer is D
Explanation
The correct answer is d) Recurrent kidney infections.
Choice A reason:
Infarction of the renal vessels is not a common consequence of vesicoureteral reflux (VUR). Infarction refers to tissue death due to a lack of blood supply, which is not typically associated with VUR1. VUR primarily affects the urinary tract, leading to the backward flow of urine from the bladder into the ureters and kidneys. This condition can cause other complications, but infarction of the renal vessels is not one of them.
Choice B reason:
Renal calculi, or kidney stones, are not directly caused by vesicoureteral reflux. While VUR can lead to urinary tract infections (UTIs), which may increase the risk of developing kidney stones, it is not the primary outcome. Kidney stones are typically formed due to an imbalance of minerals and salts in the urine, leading to crystallization. VUR itself does not directly cause the formation of renal calculi.
Choice C reason:
Urinary obstruction is not a typical result of vesicoureteral reflux. VUR involves the backward flow of urine, but it does not usually cause a physical blockage in the urinary tract. Urinary obstruction can occur due to other conditions, such as congenital abnormalities, tumors, or kidney stones, but it is not a direct consequence of VUR.
Choice D reason:
Recurrent kidney infections are a common complication of vesicoureteral reflux. The backward flow of urine can carry bacteria from the bladder into the kidneys, leading to repeated episodes of pyelonephritis (kidney infection). These recurrent infections can cause kidney damage over time if not properly managed. Therefore, it is crucial to monitor and treat VUR to prevent recurrent kidney infections and preserve kidney function.
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