A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as:
a. normal development.
b. significant developmental lag.
c. slightly delayed development due to prematurity.
d. suggestive of a neurologic disorder such as cerebral palsy.
ANS: A
Holding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. The infant is expected to be able to perform this task by age 3 months. If the child's age is corrected because of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task and the behavior is age appropriate. No evidence of neurologic dysfunction is present.
You might also like to view...
What is the legal significance of a nurse's action when a patient verbally refuses medication and the nurse gives the medication over the patient's objection? The nurse:
a. has been negligent. b. committed malpractice. c. fulfilled the standard of care. d. can be charged with battery.
Before beginning to perform a gynecological assessment, which would you ask the patient to perform?
1) Taking short, quick breaths to lessen the discomfort 2) Assuming the supine position 3) Emptying the bladder 4) Reviewing the medical history
The community health nurse manager is reviewing the charts of elderly patients. Which issue are these patients most likely to experience?
1. Adequate financial resources to purchase medications 2. Senior services that provide transportation to healthcare appointments 3. Multiple medications prescribed by different physicians 4. Medicare that covers healthcare costs so no out-of-pocket expenses occur
What factors make qualitative research challenging and need consideration when undertaking it? The terms ‘analysis' and ‘interpretation' are often used interchangeably. What is the difference between them? Why do you think that ‘interpretive description' has become an increasingly popular approach to qualitative data analysis?
What will be an ideal response?