Author Question: In assessing the amount of head lag in an infant, the nurse will: a. see how long the infant can ... (Read 34 times)

asan beg · **on:** Jun 27, 2018

In assessing the amount of head lag in an infant, the nurse will:

a. see how long the infant can hold his or her own head up, measuring the time in seconds
b. pull the infant up by the arms from a supine to a sitting position
c. measure the distance from the baby's fingertips to the ear
d. hold the baby upright in the nurse's lap and let the head fall back against the nurse's chest

Question 2

The nurse assessing an infant will be most concerned about which of the following findings?

a. peripheral cyanosis of the hands c. cyanosis of the lips or tongue
b. perioral cyanosis d. cyanosis of the feet

SVictor · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B

Feedback
A Incorrect. Head lag is not measured by timing the amount of time the infant can hold his or her head up.
B Correct. In assessing the amount of head lag in an infant, the nurse will pull the infant up by the arms from a supine to a sitting position.
C Incorrect. Head lag is not measured by measuring the distance from the baby's fingertips to the ear.
D Incorrect. Head lag is not measured by holding the baby upright in the nurse's lap and letting the head fall back against the nurse's chest.

Answer to Question 2

C

Feedback
A Incorrect. Peripheral cyanosis of the hands is usually caused by instability of the peripheral circulation system typically seen in the young infant and is not a concern. This is called acrocyanosis.
B Incorrect. The nurse will not be most concerned about perioral cyanosis (cyanosis of the skin around the lips).
C Correct. The nurse will be most concerned about cyanosis of the lips or tongue. This finding may indicate a cardiovascular alteration. Cyanosis appears when hemoglobin, approximately 5g/dl of blood, circulates unbound to oxygen and the measured oxygen saturation drops below 85.
D Incorrect. Cyanosis of the feet is usually caused by instability of the peripheral circulation system typically seen in the young infant and is not a concern. This is called acrocyanosis.