The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant:
a. Turns his or her head to localize the sound.
b. Shows no obvious response to the noise.
c. Shows a startle and acoustic blink reflex.
d. Stops any movement, and appears to listen for the sound.
ANS: A
With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen.
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