Which of the following findings is concerning to the nurse?
Absence of tears when the infant cries
Presence of vernix caseosa at delivery
Presence of anterior and posterior fontanels
Absence of the rooting reflex
The Correct Answer is D
Choice A reason: This is not a concerning finding for the nurse. Absence of tears when the infant cries is normal and expected in the first few months of life. The tear ducts and glands are not fully developed yet, and the infant does not produce enough tears to moisten the eyes or overflow the eyelids. The nurse should monitor the infant's hydration and eye health, but should not be alarmed by the absence of tears.
Choice B reason: This is not a concerning finding for the nurse. Presence of vernix caseosa at delivery is normal and expected in newborns, especially those born before 40 weeks of gestation. Vernix caseosa is a white, cheesy substance that covers the skin of the fetus in the womb. It protects the skin from the amniotic fluid and helps with temperature regulation and infection prevention. The nurse should gently wipe off the excess vernix caseosa, but should not try to remove it completely.
Choice C reason: This is not a concerning finding for the nurse. Presence of anterior and posterior fontanels is normal and expected in infants. Fontanels are soft spots on the skull where the bones have not yet fused together. They allow the skull to be flexible and accommodate the growing brain. The nurse should palpate the fontanels gently and assess their size, shape, and tension, but should not be worried by their presence.
Choice D reason: This is the concerning finding for the nurse. Absence of the rooting reflex is abnormal and unexpected in infants. The rooting reflex is an involuntary movement or response that the infant makes when the cheek or mouth is touched. The infant turns the head and opens the mouth, seeking the source of stimulation. The rooting reflex is essential for breastfeeding and feeding in general. The nurse should assess the infant's neurological status and consult with the physician if the rooting reflex is absent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the most critical stage for developing a healthy self-concept. Infancy is the stage of life from birth to 18 months, where the main psychosocial task is to develop trust versus mistrust. The infant's self-concept is not fully formed yet, but depends on the quality of the caregiver-infant relationship.
Choice B reason: This is the best answer. Adolescence is the stage of life from 12 to 18 years, where the main psychosocial task is to develop identity versus role confusion. The adolescent's self-concept is challenged by physical, cognitive, emotional, and social changes. The adolescent needs to explore and integrate different aspects of their self, such as their values, beliefs, goals, and roles. A healthy self-concept will help the adolescent to achieve a sense of identity, autonomy, and competence.
Choice C reason: This is not the most critical stage for developing a healthy self-concept. Middle adulthood is the stage of life from 40 to 65 years, where the main psychosocial task is to develop generativity versus stagnation. The middle adult's self-concept is influenced by their achievements, responsibilities, and relationships. The middle adult needs to find meaning and purpose in their life by contributing to society and the next generation. A healthy self-concept will help the middle adult to cope with the challenges of aging, work, and family.
Choice D reason: This is not the most critical stage for developing a healthy self-concept. Late adulthood is the stage of life from 65 years and older, where the main psychosocial task is to develop integrity versus despair. The late adult's self-concept is based on their life review and evaluation. The late adult needs to accept their past and present, and face their mortality. A healthy self-concept will help the late adult to achieve a sense of wisdom, dignity, and satisfaction.
Correct Answer is D
Explanation
Choice A reason: This is not the correct answer. Toddlers are the age group from 1 to 3 years old. They are curious and active, but they are not deliberately engaging in risk-taking behaviors. They may explore their environment and test their limits, but they are not aware of the potential dangers or consequences. They rely on their caregivers to provide them with safety and guidance.
Choice B reason: This is not the correct answer. Preschoolers are the age group from 3 to 5 years old. They are imaginative and playful, but they are not intentionally engaging in risk-taking behaviors. They may pretend to be superheroes or princesses, but they are not trying to harm themselves or others. They follow the rules and expectations of their caregivers and teachers.
Choice C reason: This is not the correct answer. School-age children are the age group from 6 to 12 years old. They are learning and socializing, but they are not purposely engaging in risk-taking behaviors. They may join clubs or teams, but they are not involved in illegal or immoral activities. They respect the authority and norms of their caregivers and society.
Choice D reason: This is the best answer. Adolescents are the age group from 12 to 18 years old. They are developing and experimenting, and they are more likely to engage in risk-taking behaviors. They may smoke, drink, use drugs, have sex, or break the law, as they seek thrill, novelty, or peer acceptance. They challenge the rules and values of their caregivers and society.
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