Which statements are true about an infant's neurologic status? Select all that apply.

A positive Babinski (fanning of the toes) is a normal reflex at birth.

The newborn's rooting and sucking reflexes help the baby feed.

The newborn who suddenly extends his arms in the air when he hears a loud noise is displaying the Moro reflex.

An infant will learn to sit up before he learns to roll over.

Head lag beyond 4 months may indicate brain damage.

Answer and Explanation

Correct Answer : A,B,C,E

A. A positive Babinski (fanning of the toes) is a normal reflex at birth: This reflex is expected in neonates because the corticospinal tracts are not yet fully myelinated. Dorsiflexion of the hallux and fanning of the other digits occurs in response to stroking the plantar surface. Its presence is normal until approximately 24 months of age.

B. The newborn's rooting and sucking reflexes help the baby feed: These primitive survival reflexes allow the infant to locate the nipple and initiate the mechanical process of ingestion. They are essential for early nutritional intake and are coordinated by the brainstem. These reflexes typically disappear as voluntary feeding behaviors develop later in infancy.

C. The newborn who suddenly extends his arms in the air when he hears a loud noise is displaying the Moro reflex: This involuntary startle response involves symmetrical abduction and extension of the arms, followed by adduction and crying. It is a key indicator of intact vestibular and motor systems in the neonate. Asymmetry in this reflex may suggest a clavicular fracture or brachial plexus injury.

D. An infant will learn to sit up before he learns to roll over: Motor development follows a cephalocaudal and proximodistal pattern where rolling over (trunk control) typically precedes independent sitting. Rolling usually occurs between 2 and 5 months, whereas stable sitting occurs around 6 to 7 months. This choice incorrectly reverses the standard sequence of motor milestones.

E. Head lag beyond 4 months may indicate brain damage: By 4 months, an infant should demonstrate sufficient neck muscle strength to hold the head in line with the trunk when pulled to a sitting position. Persistent head lag is a significant developmental "red flag" for motor delay. It may indicate cerebral palsy or other underlying neurological impairments.

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Correct Answer is D

Explanation

A. "Sharing needles is a big risk factor for hepatitis.": Percutaneous exposure to contaminated blood is a primary transmission route for Hepatitis B and C viruses. Sharing injection equipment allows for the direct inoculation of viral particles into the bloodstream of a susceptible host. This remains a significant public health challenge in preventing bloodborne pathogen spread.

B. "Chronic hepatitis increases the risk for liver cancer.": Persistent inflammation from Hepatitis B or C leads to progressive hepatic fibrosis and eventually cirrhosis. This chronic cellular damage and regeneration cycle predisposes hepatocytes to malignant transformation into hepatocellular carcinoma. Longitudinal monitoring of these patients for oncological changes is a standard clinical requirement.

C. "Newborns should receive the Hepatitis B vaccine.": Universal neonatal immunization is the standard of care to prevent vertical transmission and early childhood acquisition of the virus. The first dose is typically administered within 24 hours of birth to ensure long-term immunological protection. This strategy has drastically reduced the global prevalence of chronic HBV infection.

D. "Health care workers should get a Hepatitis C vaccine.": Currently, there is no commercially available vaccine for the prevention of the Hepatitis C virus. While vaccines exist for Hepatitis A and B, Hepatitis C prevention relies entirely on standard precautions and post-exposure protocols. This statement is scientifically inaccurate because the vaccine technology does not yet exist.

A. Document the oral temperature in the health care record B. Offer a blanket to prevent patient shivering C. Inspect the surgical incision for redness, swelling, heat, & pain D. Administer acetaminophen as ordered pm to reduce fever E. Notify the Health Care Provider (HCP)

Correct Answer is ["A","C","D","E"]

Explanation

A. Document the oral temperature in the health care record: Accurate documentation of vital signs is a legal and clinical necessity for tracking the patient's postoperative trajectory. A temperature of 38°C represents a low-grade pyrexia that must be recorded to establish a trend. This data is essential for subsequent clinical decision-making and interdisciplinary communication.

B. Offer a blanket to prevent patient shivering: While blankets provide comfort, they can further insulate a febrile patient and cause a paradoxical rise in core body temperature. Shivering is a physiological mechanism to generate heat, but external warming during a fever is generally contraindicated unless the patient is in the chill phase. Nursing interventions should focus on heat dissipation.

C. Inspect the surgical incision for redness, swelling, heat, & pain: Assessment of the operative site is critical to differentiate between physiological postoperative inflammation and early surgical site infection. The nurse must evaluate for localized rubor, tumor, calor, and dolor as part of a comprehensive febrile workup. This helps identify the potential source of the elevated temperature.

D. Administer acetaminophen as ordered pm to reduce fever: Acetaminophen acts on the hypothalamic heat-regulating center to reduce fever and provide postoperative analgesia. Administration is appropriate when the temperature meets the threshold defined in the standing PRN orders. This intervention improves patient comfort and reduces the metabolic demands associated with pyrexia.

E. Notify the Health Care Provider (HCP): While low-grade fevers are common within 24 hours of surgery due to atelectasis or inflammatory stress, the HCP must be informed of any deviations from baseline. This ensures that the surgical team can order diagnostic tests, such as a chest X-ray or urinalysis, if indicated. Timely notification is a key component of postoperative surveillance.

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Which statements are true about an infant's neurologic status? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which statement is NOT correct?

Correct Answer is D

Explanation

The nurse cares for a patient who is one day post-op surgery. The nurse checks the patient's oral temperature and notes that it is 38° Celsius. Which action by the nurse is appropriate? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

An adult female patient reports black stools. Which follow up question is most important for the nurse to ask?

An adult male reports urinary frequency and difficulty starting the flow of urine. Which condition is likely?

Which of the following is common when a patient's nutritional reserves are depleted? Select all that apply.

The nurse is assessing a patient's active range of motion (ROM) and notices limited extension at the left elbow. What is the next step for the nurse to take?

Which is a function of the musculoskeletal system? Select all that apply.

The patient has a spinal anesthetic block to the T-10 level. Which landmark is associated with T-10?

The school nurse is assessing a student for scoliosis. When comparing the right and left sides, which landmark, if uneven, could indicate a problem? Select all that apply.

A 16-year-old patient who is six months post wrist fracture is in for a follow up visit. The nurse assesses the range of motion (ROM) of the affected arm and notes which bones are involved in pronation and supination of the forearm?