The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

The child exhibits plantar grasp reflex.

The child has doubled his birth weight.

No primary teeth have erupted yet.

The child's head circumference is 49.53 cm.

Answer and Explanation

The Correct Answer is C

A. The child exhibits plantar grasp reflex: The presence of the plantar grasp reflex at 10 months

is appropriate and not cause for concern. This reflex typically diminishes by around 9 months but can persist slightly longer in premature infants.

B. The child has doubled his birth weight: Doubling birth weight by around 6 months is a normal developmental milestone, and achieving this by 10 months is appropriate, indicating healthy growth.

C. No primary teeth have erupted yet: The absence of primary teeth by 10 months, especially in a preterm infant, may indicate a delay in dental development and should prompt further evaluation by a healthcare provider.

D. The child's head circumference is 49.53 cm: The head circumference of 49.53 cm falls within the typical range for a 10-month-old infant and is not inherently concerning.

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Correct Answer is B

Explanation

A. "This is normal behavior for infants unless the stool passed is black or green.": While black or green stools may indicate potential issues, grunting and crying during bowel movements are common behaviors in infants and are not necessarily indicative of a problem.

B. "This is normal behavior for infants due to the immaturity of the gastrointestinal system.": Grunting and crying during bowel movements are typical behaviors in infants, especially during the first few months of life. This is because the infant's gastrointestinal system is still developing and they may have difficulty coordinating their muscles to pass stool smoothly.

C. "This is normal behavior for infants unless the stool passed is hard and dry.": While hard and dry stools may indicate constipation, grunting and crying during bowel movements can still be normal behaviors in infants, regardless of the consistency of the stool.

D. "This indicates a blockage in the intestine and must be reported to the health care provider.": Grunting and crying during bowel movements are not necessarily indicative of a blockage in the intestine. These behaviors are common in infants and usually resolve as the infant's gastrointestinal system matures.

A. The child does not vocally respond to voices. B. The child never squeals or yells. C. The child does not babble. D. The child does not say dada or mama.

Correct Answer is C

Explanation

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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The nurse is examining a 10-month-old boy who was born 10 weeks early. Which finding is cause for concern?

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