In the assessment of a 1-month-old infant, the nurse notices a ...

[skymedlock]

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry.
 
  The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?
  a.
  Refer the infant for further testing.
  b.
  Talk with the mother about eating habits.
  c.
  Do nothing; these are expected findings for an infant this age.
  d.
  Tell the mother to bring the baby back in 1 week for a recheck.

Question 2

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?
 
  a. Positive Babinski sign
  b. Plantar reflex abnormal
  c. Plantar reflex present
  d. Plantar reflex 2+ on a scale from 0 to 4+

[angrybirds13579]

Answer to Question 1

ANS: A
A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.

Answer to Question 2

ANS: C
With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

[skymedlock]

Correct answers!

[angrybirds13579]

Great! Please up vote