Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a 3-month-old infant.
Which of the following findings should the nurse report to the provider?
A. The infant is unable to roll from the back to the abdomen.
Choice A is not correct because it is normal for a 3-month-old infant to be unable to roll from back to abdomen.
B. The infant is unable to use a pincer grasp to pick up objects.
Choice B is not correct because it is normal for a 3-month-old infant to be unable to use a pincer grasp to pick up objects.
C. The infant is unable to raise his head when in a prone position.
By 3 months old, most babies can lift their heads and chest up from a belly-down position.
D. The infant is unable to sit without support.
Choice D is not correct because it is normal for a 3-month-old infant to be unable to sit without support.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom- Wn23 NS122 Proctored Exam. Take the full exam now
Full Explanation
By 3 months old, most babies can lift their heads and chest up from a belly-down position.
Choice A is not correct because it is normal for a 3-month-old infant to be unable to roll from back to abdomen.
Choice B is not correct because it is normal for a 3-month-old infant to be unable to use a pincer grasp to pick up objects.
Choice D is not correct because it is normal for a 3-month-old infant to be unable to sit without support.
Similar Questions
The nursing instructor is leading a discussion on the physical changes to a woman's body after the delivery of the baby.
The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
A. Evolution.
Choice A is not correct because evolution refers to the gradual development of something.
B. Decrement.
Choice B is not correct because decrement refers to a reduction in size or value.
C. Progression.
Choice C is not correct because progression refers to the process of developing or moving gradually toward a more advanced state.
D. Involution.
Involution is the process by which the uterus returns to its nonpregnant size and function after delivery.
Full Explanation
Involution is the process by which the uterus returns to its nonpregnant size and function after delivery.
Choice A is not correct because evolution refers to the gradual development of something.
Choice B is not correct because decrement refers to a reduction in size or value.
Choice C is not correct because progression refers to the process of developing or moving gradually toward a more advanced state.
A nurse is collecting data from a client who is 14 hr postpartum.
The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F); pulse rate 88/min; respiratory rate 18/min.
Which of the following actions should the nurse perform?
A. Report the client's temperature elevation.
Choice A is not correct because a temperature of 37.7° C (100° F) is within the normal range for a postpartum client.
B. Encourage the client to nurse more frequently so her milk will come in.
Choice B is not correct because the client’s milk production is not related to the findings noted by the nurse.
C. Ask the client to empty her bladder.
A full bladder can displace the uterus and cause it to deviate to one side.
D. Increase IV fluids.
Choice D is not correct because there is no indication that the client needs an increase in IV fluids.
Full Explanation
A full bladder can displace the uterus and cause it to deviate to one side.
Choice A is not correct because a temperature of 37.7° C (100° F) is within the normal range for a postpartum client.
Choice B is not correct because the client’s milk production is not related to the findings noted by the nurse.
Choice D is not correct because there is no indication that the client needs an increase in IV fluids.
A nurse is collecting data from a 9-month-old infant.
Which of the following findings requires a nursing intervention?
A. Positive Moro reflex.
Choice A reason: Positive Moro reflex: This reflex should disappear by 6 months of age. Its presence at 9 months indicates potential neurological issues.
B. Negative Doll's eye reflex.
Choice B reason: Negative Doll’s eye reflex: This reflex, indicating brainstem function, should be positive in infants. A negative result suggests severe brainstem dysfunction
C. Positive Babinski reflex.
Choice C reason: Positive Babinski reflex: This reflex is normal up to 2 years of age. It indicates normal neurological development in infants.
D. Negative Crawl reflex.
Choice D reason: Negative Crawl reflex: Crawling typically develops between 6-10 months. A negative crawl reflex at 9 months could indicate developmental delays
Full Explanation
The correct answer is a. Positive Moro reflex.
Choice A reason:
Positive Moro reflex: This reflex should disappear by 6 months of age. Its presence at 9 months indicates potential neurological issues.
Choice B reason:
Negative Doll’s eye reflex: This reflex, indicating brainstem function, should be positive in infants. A negative result suggests severe brainstem dysfunction
Choice C reason:
Positive Babinski reflex: This reflex is normal up to 2 years of age. It indicates normal neurological development in infants.
Choice D reason:
Negative Crawl reflex: Crawling typically develops between 6-10 months. A negative crawl reflex at 9 months could indicate developmental delays