This topic contains a solution. Click here to go to the answer

Author Question: In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or ... (Read 261 times)

skymedlock

  • Hero Member
  • *****
  • Posts: 561
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+



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

angrybirds13579

  • Sr. Member
  • ****
  • Posts: 344
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.





 

Did you know?

Studies show that systolic blood pressure can be significantly lowered by taking statins. In fact, the higher the patient's baseline blood pressure, the greater the effect of statins on his or her blood pressure.

Did you know?

Recent studies have shown that the number of medication errors increases in relation to the number of orders that are verified per pharmacist, per work shift.

Did you know?

Carbamazepine can interfere with the results of home pregnancy tests. If you are taking carbamazepine, do not try to test for pregnancy at home.

Did you know?

About 3% of all pregnant women will give birth to twins, which is an increase in rate of nearly 60% since the early 1980s.

Did you know?

Methicillin-resistant Staphylococcus aureus or MRSA was discovered in 1961 in the United Kingdom. It if often referred to as a superbug. MRSA infections cause more deaths in the United States every year than AIDS.

Methicilli ...

For a complete list of videos, visit our video library