During a routine assessment of an 8-month-old, the nurse is assessing primitive reflexes. Which finding should the nurse expect for an infant of this age?
When hearing a loud noise, the infant cries and extends both arms and legs.
When stroking the outer edge of the sole of the infant's foot, the toes fan upward and out.
When infant's head is turned to one side, extension of the same side arm and leg occurs.
When stroking the cheek, the infant turns toward that side of stimulation.
The Correct Answer is B
Rationale:
A. The Moro reflex, where the infant cries and extends both arms and legs in response to a loud noise, typically disappears by 4-6 months of age and would not be expected at 8 months.
B. The Babinski reflex, where the toes fan upward and out when the outer edge of the sole is stroked, is normal in infants and usually disappears by 12-24 months of age.
C. The tonic neck reflex (fencing reflex) typically disappears around 4-6 months of age, so it would not be expected in an 8-month-old.
D. The rooting reflex, where the infant turns their head toward the side of stimulation when the cheek is stroked, typically disappears by 3-4 months of age.
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Correct Answer is A
Explanation
Rationale:
A. Hemophilia is a bleeding disorder that affects the clotting process, and the partial thromboplastin time (PTT) is typically prolonged in individuals with hemophilia, indicating a deficiency in clotting factors.
B. Hemoglobin levels may remain normal unless the client experiences significant bleeding episodes.
C. Platelet count is usually normal in hemophilia, as the disorder affects clotting factors rather than platelet production.
D. Hematocrit levels may also remain normal unless there is significant bleeding, which would lower hematocrit due to blood loss.
Correct Answer is D
Explanation
Rationale:
A. Increasing fluid intake is important for overall health but is not the primary concern in the initial management of bladder exstrophy.
B. Inserting a catheter may be necessary but is not the first priority in managing bladder exstrophy.
C. Prone positioning is generally not recommended for infants with bladder exstrophy; supine positioning may be preferable to prevent pressure on the exposed bladder.
D. Preventing skin breakdown is critical due to the constant exposure of the bladder and surrounding skin to urine, leading to a high risk of irritation and infection.