HESI RN Med Surg
HESI RN Med Surg ( 40 Questions)
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
Playing "peek-a-boo" is a normal behavior for a 6-month-old infant. It shows that the infant has developed object permanence, which is the understanding that objects and people still exist even when they are out of sight. This is a sign of cognitive development and social interaction.
Turning head to locate sound is a normal behavior for a 6-month-old infant. It shows that the infant has developed auditory localization, which is the ability to identify the direction and distance of a sound source. This is a sign of sensory development and curiosity.
Having doubled birth weight is a normal milestone for a 6-month-old infant. It shows that the infant has adequate growth and nutrition. The average birth weight for a full-term infant is about 3.4 kg (7.5 lb), and the average weight for a 6-month-old infant is about 6.8 kg (15 lb).
Demonstrating startle reflex is an abnormal behavior for a 6-month-old infant. The startle reflex, also known as the Moro reflex, is an involuntary response to a sudden loud noise or movement. The infant will extend the arms and legs, arch the back, and then curl the arms and legs inward. This reflex is present at birth and usually disappears by 4 months of age. If the reflex persists beyond 6 months of age, it may indicate a neurological problem or developmental delay. The nurse should request further evaluation by the health care provider.
Choice A reason: Playing "peek-a-boo" is a normal behavior for a 6-month-old infant. It shows that the infant has developed object permanence, which is the understanding that objects and people still exist even when they are out of sight. This is a sign of cognitive development and social interaction.
Choice B reason: Turning head to locate sound is a normal behavior for a 6-month-old infant. It shows that the infant has developed auditory localization, which is the ability to identify the direction and distance of a sound source. This is a sign of sensory development and curiosity.
Choice C reason: Having doubled birth weight is a normal milestone for a 6-month-old infant. It shows that the infant has adequate growth and nutrition. The average birth weight for a full-term infant is about 3.4 kg (7.5 lb), and the average weight for a 6-month-old infant is about 6.8 kg (15 lb).
Choice D reason: Demonstrating startle reflex is an abnormal behavior for a 6-month-old infant. The startle reflex, also known as the Moro reflex, is an involuntary response to a sudden loud noise or movement. The infant will extend the arms and legs, arch the back, and then curl the arms and legs inward. This reflex is present at birth and usually disappears by 4 months of age. If the reflex persists beyond 6 months of age, it may indicate a neurological problem or developmental delay. The nurse should request further evaluation by the health care provider.