while performing a physical assessment on a 6 month old infant the nurse observes head lag which of the following nursing actions should the nurse per

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?

A. Ask the parents to allow the infant to lie on his stomach to promote muscle development.
B. Notify the physician because a developmental or neurological evaluation is indicated.
C. Document the findings as abnormal in the nurse's notes.
D. Explain to the parents that their child is likely to have developmental delays.

Correct answer: B

Rationale: Head lag should be completely resolved by 4 months of age. Continuing head lag at 6 months of age indicates the need for further developmental or neurological evaluation. Laying the infant on his stomach promotes muscle development of the neck and shoulder muscles, but because of the age of this child, a referral should be the first action. The findings are abnormal for a 6-month-old infant. Significant head lag can be seen in infants with Down syndrome and hypoxia, as well as neurological and other metabolic disorders. While some of these disorders might include developmental delays, stating this to the parents without a proper evaluation can cause unnecessary distress. The priority is to identify the cause of the head lag through a medical evaluation before discussing potential outcomes with the parents.

2. Which of these is not a symptom of Serotonin Syndrome?

A. edema
B. fever
C. confusion
D. tremors

Correct answer: A

Rationale: Serotonin syndrome, caused by an excess of serotonin, typically presents with symptoms such as altered mental status (confusion), neuromuscular abnormalities (tremors), and autonomic dysfunction (fever). Edema, which refers to swelling caused by fluid retention in the body tissues, is not a common symptom associated with serotonin syndrome. Therefore, the correct answer is 'edema.' Choice A, 'edema,' is the correct answer as it is not typically seen in serotonin syndrome. Choice B, 'fever,' is a symptom of serotonin syndrome, as it can cause autonomic dysfunction. Choice C, 'confusion,' is a common symptom due to altered mental status in serotonin syndrome. Choice D, 'tremors,' is also a common symptom due to neuromuscular abnormalities in serotonin syndrome.

3. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

A. "I should not put alcohol on my baby's cord 3-4 times a day."?
B. "I should not put the baby's diaper on so that it covers the cord."?
C. "I should call the physician if the cord becomes dark."?
D. "I should wash my hands before and after I take care of the cord."?

Correct answer: B

Rationale: Parents should be taught not to cover the cord with a diaper to allow for air exposure and drying, preventing infection. The statement 'I should put alcohol on my baby's cord 3-4 times a day' indicates a need for further teaching as current recommendations do not include using alcohol on the cord, which can interfere with natural healing. While it is normal for the cord to turn dark as it dries, so the statement 'I should call the physician if the cord becomes dark' is accurate, it is not the best answer for this question. Washing hands before and after caring for the cord is important to prevent the transfer of pathogens, so this statement does not require further teaching.

4. When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:

A. Have the client sign the permit, as he verbalizes understanding.
B. Witness the form after having the client sign it.
C. Have his wife sign the form as she witnessed him saying he wants the surgery.
D. Call the surgical area and explain the surgery will have to be cancelled.

Correct answer: D

Rationale: The correct action in this scenario is to call the surgical area and explain that the surgery will have to be cancelled. The client must sign the operative permit or any other legal document before receiving preoperative medication. Without the signed permit, the surgery cannot proceed to ensure the client's safety and legal compliance. Having the client sign the permit, witnessing the form after the client signs it, or having someone else sign the form are all inappropriate actions and do not address the legal requirement of the client's signature before receiving preoperative medication.