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 D
Explanation
Rationale:
A. While explaining discharge instructions is important, it is not the immediate priority following cast application.
B. Educating the client to elevate the leg is important to reduce swelling, but it is not the first priority.
C. Administering pain relief is necessary, but assessing circulation, sensation, and movement is more critical to identify any early signs of complications.
D. Performing a neurovascular assessment is the priority action because it ensures that there is no compromise to blood flow, sensation, or movement in the affected limb, which could indicate complications such as compartment syndrome.
Correct Answer is B
Explanation
Rationale:
A. Changing routines frequently might confuse the child rather than stimulate initiative.
B. Rewarding the child for showing initiative positively reinforces the behavior and encourages further development.
C. Allowing the child to make choices about playmates can foster independence but may not directly stimulate initiative.
D. Setting appropriate limits is important for a child's development, but not setting any limits can lead to behavioral issues rather than promoting initiative.