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 B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

A. Covert B. Subjective C. Objective D. Symptomatic

Correct Answer is C

Explanation

A. Covert: Covert data refers to information that is hidden, subjective, or not immediately observable, such as symptoms reported by the client. Voided volume is measurable and observable, so it is not covert.

B. Subjective: Subjective data is information reported by the client, such as feelings, perceptions, or symptoms. Since the urine output is a measurable and observable fact, it is not subjective.

C. Objective: Objective data is factual, measurable, and observable. The voided volume of 475 ml is a precise, quantifiable measurement, making it objective data.

D. Symptomatic: Symptomatic data pertains to symptoms experienced by the client, which are typically subjective. The documented urine output is a specific, quantifiable measurement and not a symptom.

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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

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Correct Answer is B

Explanation

At the end of the shift, the nurse documents that the client has voided 475 ml during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Correct Answer is C

Explanation

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