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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Appearance of pubic hair around 11 to 13 years old - Pubic hair development typically occurs around the ages of 11 to 13 in girls, signaling the onset of puberty. This is a normal part of physical development.
B. Swelling or redness of the labia minora - Swelling or redness of the labia minora may indicate inflammation or infection, unrelated to normal puberty development.
C. Lesions on the external genitalia - Lesions on the external genitalia are not normal signs of puberty and may indicate a medical issue requiring evaluation and treatment.
D. Presence of labial adhesions - Labial adhesions, where the labia minora stick together, are not directly related to puberty onset and may require medical attention if they cause discomfort or urinary issues
Correct Answer is A
Explanation
A. 87 lb is a reasonable weight for a 10-year-old boy who was 80 lb the previous year, considering the average weight gain is about 10 pounds a year at this age.
B. 81 lb would be a below-average weight gain for a year for a child of this age. C. 89 lb would be an above-average weight gain for a year for a child of this age.
D. 85 lb is within the range but slightly below the average expected weight gain for a year for a child of this age.
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