In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry
The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?
a.
Refer the infant for further testing.
b.
Talk with the mother about eating habits.
c.
Do nothing; these are expected findings for an infant this age.
d.
Tell the mother to bring the baby back in 1 week for a recheck.
ANS: A
A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.
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