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 D
Explanation
Choice A reason: This is not a statement that indicates a distorted body image. The client may have a high or unrealistic expectation of their functional ability, but it does not mean that they have a negative or inaccurate perception of their appearance.
Choice B reason: This is not a statement that indicates a distorted body image. The client may be experiencing grief or depression, but it does not mean that they have a low or distorted self-esteem.
Choice C reason: This is not a statement that indicates a distorted body image. The client may be feeling anger or resentment, but it does not mean that they have a poor or distorted self-image.
Choice D reason: This is the statement that indicates a distorted body image. The client shows a sign of avoidance or denial of their amputated limb. This implies that the client has a distorted body image and a negative self-concept.
Correct Answer is A
Explanation
Choice A reason: This is the best answer. Parallel play is a type of play that occurs when toddlers play near each other, but not with each other. They may use similar toys or activities, but they do not interact or share. Parallel play is a normal and common stage of play development for toddlers, as they are still learning to socialize and cooperate with others.
Choice B reason: This is not a likely type of play for toddlers. Use aggressive interactions is a behavior that involves hitting, biting, pushing, or yelling at other children. It may occur when toddlers are frustrated, angry, or jealous, or when they do not have the language or social skills to express their feelings or needs. Use aggressive interactions is not a desirable or appropriate behavior for toddlers, and it should be discouraged and corrected by adults.
Choice C reason: This is not a likely type of play for toddlers. Demonstrate fear is an emotion that involves feeling scared, anxious, or nervous about something. It may occur when toddlers are exposed to unfamiliar or threatening situations, people, or objects. Demonstrate fear is not a type of play, but a reaction that may prevent toddlers from playing or exploring.
Choice D reason: This is not a likely type of play for toddlers. Join in with the other children is a type of play that occurs when toddlers play together, cooperate, and share. They may use the same toys or activities, and interact with each other. Join in with the other children is a more advanced stage of play development for toddlers, as it requires more language and social skills. Most toddlers are not ready for this type of play until they are older.
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