A nurse is assessing a 4-month-old infant on a pediatric unit.
Which of the following findings should the nurse expect?
Uses thumb and index fingers in a pincer grasp.
Closed posterior fontanel.
Lateral incisors.
Sitting steadily without support.
The Correct Answer is B
Choice A rationale
A pincer grasp, using the thumb and index finger to pick up small objects, typically develops around 9 to 12 months of age, not at 4 months.
Choice B rationale
The posterior fontanel typically closes by the age of 2 to 3 months, so a 4-month-old infant would be expected to have a closed posterior fontanel. This finding is consistent with normal development.
Choice C rationale
Lateral incisors, the teeth on either side of the front teeth, typically erupt around 9 to 13 months of age, not at 4 months.
Choice D rationale
Sitting steadily without support generally occurs closer to 6 to 8 months of age, so it would not be expected in a 4-month-old infant.
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Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Measles, mumps, rubella (MMR) vaccine is recommended for a 1-year-old child as it protects against these three highly contagious viral diseases. This vaccine is typically given in two doses, with the first dose administered at 12-15 months.
Choice B rationale
Tetanus, diphtheria, and pertussis (TDaP) vaccine is not typically given at 1 year of age. The primary series is given in infancy, and the TDaP booster is given at 4-6 years of age.
Choice C rationale
Inactivated polio virus (IPV) vaccine is part of the routine vaccination schedule for children. It protects against polio, a serious disease that can cause paralysis. The IPV vaccine is given in multiple doses, starting at 2 months of age.
Choice D rationale
Varicella (VAR) vaccine protects against chickenpox, a highly contagious disease. It is recommended for children at 12-15 months of age and is usually given in two doses.
Choice E rationale
Human papillomavirus (HPV) vaccine is not recommended for a 1-year-old child. It is typically given to preteens and teens to protect against HPV infections that can lead to cervical cancer and other diseases.
Correct Answer is C
Explanation
Choice A rationale
An APGAR score of 5 indicates significant distress and poor adjustment to extrauterine life, which is not consistent with the provided description of the infant's condition.
Choice B rationale
An APGAR score of 6 suggests moderate difficulty with extrauterine adaptation, which is still not entirely consistent with the overall assessment of the infant.
Choice C rationale
An APGAR score of 7 aligns with the described observations of the newborn: pink trunk and head, bluish extremities, active movement, heart rate of 130/min, and a response to
suctioning, which suggest the infant is in reasonably good condition with some minor issues that need monitoring.
Choice D rationale
An APGAR score of 8 would indicate that the newborn is in very good condition with only slight adjustments needed, which does not fully match the infant's description with the noted
issues like a weak cry and bluish extremities.