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NurseDive Free Nursing Practice Question
A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?
A. No head lag when pulled to a sitting position
No head lag when pulled to a sitting position is a normal finding at 4 months of age.
B. Doll's eye reflex intact
They should not have doll's eye reflex intact, which means that their eyes move in the opposite direction of their head when turned. This reflex normally disappears by 3 months of age and its persistence may indicate brain damage.
C. Presence of tears when crying
The presence of tears when crying is a normal finding at 4 months of age.
D. Positive Babinski reflex
They should also have positive Babinski reflex, which means that their toes fan out when their sole is stroked. This reflex normally disappears by 12 months of age.
This question is an excerpt from Nurse Dive's nursing test bank - Rn Pediatric Nursing 2023 Proctored Exam. Take the full exam now
Full Explanation
A. No head lag when pulled to a sitting position is a normal finding at 4 months of age.
B. They should not have doll's eye reflex intact, which means that their eyes move in the opposite direction of their head when turned. This reflex normally disappears by 3 months of age and its persistence may indicate brain damage.
C. The presence of tears when crying is a normal finding at 4 months of age.
D. They should also have positive Babinski reflex, which means that their toes fan out when their sole is stroked. This reflex normally disappears by 12 months of age.
Similar Questions
A nurse is obtaining informed consent for an adolescent who is scheduled for a cardiac catheterization. The adolescent's guardian states, "I don't understand why they need to do this procedure." Which of the following actions should the nurse take?
A. Request assistance from the anesthesiologist to clarify the misunderstanding.
Requesting assistance from the anesthesiologist may not be necessary at this point and does not address the guardian's lack of understanding.
B. Explain the procedure to the adolescent and their guardian.
Explaining the procedure to the adolescent and their guardian is the appropriate action to address the guardian's concerns and ensure they fully understand the procedure and its necessity.
C. Witness the adolescent's signature on the informed consent form.
Witnessing the adolescent's signature on the informed consent form is appropriate after the procedure has been explained and the guardian's questions have been addressed.
D. Notify the provider who is scheduled to perform the procedure.
Notifying the provider who is scheduled to perform the procedure may be necessary but does not address the guardian's lack of understanding and does not ensure informed consent.
Full Explanation
A. Requesting assistance from the anesthesiologist may not be appropriate as they may not be as familiar with the specifics of the procedure as the provider performing it.
B. Explaining the procedure is not the nurse's role.
C. Witnessing the signature is a procedural task that does not address the guardian's need for understanding the necessity of the procedure.
D. Notifying the provider is the most appropriate action because they can provide a detailed explanation and answer specific questions the guardian may have, ensuring informed consent is truly informed.
A nurse is reviewing the laboratory results of a child who was recently admitted for suspected rheumatic fever. The nurse should identify that which of the following laboratory tests can contribute to confirming this diagnosis?
Select all that apply.
A. Partial thromboplastin time (PTT)
Partial thromboplastin time (PTT) is not typically used in the diagnosis of rheumatic fever.
B. C-reactive protein (CRP)
C-reactive protein (CRP) is elevated in cases of inflammation and can help confirm the diagnosis of rheumatic fever.
C. Erythrocyte sedimentation rate (ESR)
Erythrocyte sedimentation rate (ESR) is another marker of inflammation that can be elevated in rheumatic fever.
D. Antistreptolysin O (ASO) titer
Antistreptolysin O (ASO) titer measures antibodies against streptolysin O produced by Group A Streptococcus, which can indicate recent streptococcal infection, contributing to the diagnosis of rheumatic fever.
E. Blood urea nitrogen (BUN)
Full Explanation
A. Partial thromboplastin time (PTT) is not typically used in the diagnosis of rheumatic fever.
B. C-reactive protein (CRP) is elevated in cases of inflammation and can help confirm the diagnosis of rheumatic fever.
C. Erythrocyte sedimentation rate (ESR) is another marker of inflammation that can be elevated in rheumatic fever.
D. Antistreptolysin O (ASO) titer measures antibodies against streptolysin O produced by Group A Streptococcus, which can indicate recent streptococcal infection, contributing to the diagnosis of rheumatic fever.
E. Blood urea nitrogen (BUN) is not directly related to the diagnosis of rheumatic fever.
A nurse is caring for a 5-year-old child following a tonsillectomy and adenoidectomy. Which of the following findings should the nurse identify as an indication of hemorrhage?
A. Heart rate 54/min
A heart rate of 54/min is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
B. Flushing of the face
Flushing of the face is not a direct indicator of hemorrhage.
C. Blood pressure 95/56 mm Hg
A blood pressure of 95/56 mm Hg may be within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
D. Continuous swallowing
Continuous swallowing can indicate bleeding in the postoperative period following a tonsillectomy and adenoidectomy, as blood may be pooling in the throat and swallowed rather than expectorated.
Full Explanation
A. A heart rate of 54/min is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
B. Flushing of the face is not a direct indicator of hemorrhage.
C. A blood pressure of 95/56 mm Hg may be within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
D. Continuous swallowing can indicate bleeding in the postoperative period following a tonsillectomy and adenoidectomy, as blood may be pooling in the throat and swallowed rather than expectorated.