You're assessing a 4-month-old infant. Which finding below is a normal milestone that should be reached by this infant at this age?

Pincer grasp

Rolls from tummy to back

Walks with support

Rolls from back to tummy

Answer and Explanation

The Correct Answer is B

A. Pincer grasp: The pincer grasp, which involves using the thumb and forefinger to pick up small objects, typically develops around 8 to 12 months of age, not at 4 months.

B. Rolls from tummy to back: At 4 months, many infants start to develop the ability to roll from their tummy to their back. This is a typical milestone for this age and reflects developing motor skills.

C. Walks with support: Walking with support usually begins around 9 to 12 months of age, much later than 4 months.

D. Rolls from back to tummy: Rolling from back to tummy typically occurs a bit later, often around 5 to 6 months. At 4 months, rolling from tummy to back is the more expected milestone.

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Correct Answer is A

Explanation

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

A. Provide music as an environmental distraction. B. Make sure the room temperature is cool. C. Explain to the client what is about to happen. D. Inform the client that the provider will examine sensitive areas first

Correct Answer is C

Explanation

A. Provide music as an environmental distraction: This might help in some contexts but is not typically necessary for preparing for a physical exam. Clear communication is more important.

B. Make sure the room temperature is cool: Older adults often have reduced ability to regulate body temperature and may find cooler environments uncomfortable. A comfortable room temperature is preferable.

C. Explain to the client what is about to happen: Clear explanations can reduce anxiety, increase cooperation, and ensure that the client understands the process, which is crucial for effective assessment and trust.

D. Inform the client that the provider will examine sensitive areas first: Sensitive areas are usually examined last to maintain comfort and build trust.

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You're assessing a 4-month-old infant. Which finding below is a normal milestone that should be reached by this infant at this age?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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