NR 509 final exam 8 Questions with answers, Exams of Nursing

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NR 509 final exam 8 Questions with

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Palmer Grasp Reflex ✔the infant will flex all finger to grasp your finger. *If seen beyond 4 mo= pyramidal tract dysfunction. Persistance of a clinched hand over 2 mo=CNS damage *especially if fingers overlap the thumb. Plantar grasp reflex ✔6-8 mo Touch the sole at the base of the toes , the toes will curl. -reflex after 8 months suggest pyramidal tract dysfunction. Moro reflex (startle reflex) ✔Birth to 4 persistence beyond 4 mo =cerebral palsy, asymmetric response = fx clavicle, humerus, brachial plexus injury. Rooting reflexterm- ✔3-4 mo. absence- CNS disease Asymmetric Tonic Neck Reflex ✔Birth- 2 mo infant supine turn head to one side holding jaw over shoulder the arms/legs on side to which head is turned will extend while the opposite arm/leg flex. Birth -2 mo. Persistence beyond 2 months suggest asymmetric central nervous system development/ cerebral palsy Trunk incurvation (Galant) Reflex ✔Support the infant prone with one hand and stroke one side of the back 1 cm from midline from shoulder to buttocks. The spine will curve toward stimulated side. Absence: transverse spinal cord lesion or injury, persistence may indicate delayed development. Landau Reflex ✔Birth- 6 mo suspend infant prone with one hand the head will flip up and the spine will straighten. Persistence may indicate delayed development Parachute Reflex

✔8 mo. does not disappear. Prone lower head toward surface arms and legs will extend in a protective fashion. Delay in appearance- future delays in voluntary motor development. Positive support reflex ✔Birth or 2 mo - 6 mo Hold the infant around the trunk and lower until the feet touch a flat surface the hips and knees with extend infant will stand up and partially bear weight. Lack of reflex suggests hypotonia or flaccidity, fixed extension and adduction of the legs (scissoring) suggest spasticity from neurologic disease (cerebral palsy) Placing and stepping reflexes ✔Hold the infant upright as in positive support reflex have one sole touch the tabletop the hip and knee of that foot with flex and the other foot with stem forward alternative stepping with occur. Absence of placing may indicate paralysis, NB by breech delivery may not have reflex. Developmental milestones 1 year ✔walk/run 2-3 single words, peek a boo, separation anxiety Developmental milestones 2 year ✔throws a ball overhand, 2-3 word phrases, draws circles, imitates activities, prefers to do things themselves at times. Developmental milestone 3 ✔pedals tricycle, jumps in place, feeds self with utensils, knows colors, sentences, asks why?, sings songs, knows self in mirror, knows gender Developmental milestone 4 ✔cuts with scissors, hops, balances on one foot, understands speech 100%, talks in paragraphs, says abcs, copies figures, defines words. Developmental milestone 5 ✔copies skips, balances well on one foot. Walks on tip toes, says ABCs Copies figures, defines words, dresses self buttons zips, plays games, knows whole name and # Vaccinations and pregnancy ✔Tdap administered between 27-36 wks of gestation regardless of prior immunization history. * inactivated influenza vaccine is recommended at anytime during the pregnancy during flu season. Safe vaccines: pneumococcal, meningiococcal, hep b, A, pneumococcal polysaccharide.

*NOT safe- MMR, polio, varicella Estimated date of confinement ✔40 wks from first date of LMP Naegeles rule ✔LMP + 7 days, subtract 3 months and add 1 year. Tanner staging female 1 breast ✔preadolescent development of nipple only Tanner staging female 2 breast ✔breast bud stage, elevation of breast and nipple as small mound, enlargement of areolar diameter Tanner female stage 3 breast ✔further enlargement of elevation of breast and areola with no separation of their contours tanner stage 1 pubic hair female ✔preadolecent- no pubic hair except for fine body hair (vellus hair) similar to that on abdomen Tanner female stage 4 breast ✔projection of areola and nipple to form a secondary mound about the level of breast Tanner stage 2 pubic hair ✔sparse growth of long slightly pigmented downy hair strait or only slightly curled Tanner female stage 5 (Mature stage) breast ✔projection of nipple only; areola has receded to general contour of the breast (although in some normal individuals the areola continues to form a secondary mold. Tanner stage 3 pubic hair ✔darker, coarser, curlier hair, spreading sparsely over the pubic symphysis Tanner female stage 4 pubic hair

✔coarse and curly hair as in adults area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs. Tanner female stage 5 pubic hair ✔Hair adult in quantity and quality spreads on the medial surface of the thighs but not up over the abdomen. Male tanner scale ✔Male external genitalia scale Stage 1: Testicular volume < 4 ml or long axis < 2.5 cm Stage 2: 4 ml-8 ml (or 2.5-3.3 cm long), 1st pubertal sign in males Stage 3: 9 ml-12 ml (or 3.4-4.0 cm long) Stage 4: 15-20 ml (or 4.1-4.5 cm long) Stage 5: > 20 ml (or > 4.5 cm long) Hepatitis B Vaccine ✔Birth, 1-2 mo, 6-15 mo Rotavirus, Dtap <7, Polio (inactivated, HIB (type B), pneumococcal, ✔2 mo, 4 mo, & 6 mo (if 3rd vaccination needed) Stage 1 male ✔preadolecent no pubic hair Penis- same size as childhood Testies Scrotum- " " Stage 2 male ✔Sparse growth of long slightly pigmented downy hair Penis: Slight or no enlargement Testes/ Scrotum: larger somewhat reddened and altered in texture Stage 3 male ✔Darker, coarser, curlier hair spreding sparsely over the pubic symphysis Penis: larger especially in length Testes/Scrotum: Further enlarged Stage 4 male ✔Course and curly hair as in the adult but not yet over the thighs. influenza ✔6 mo, annually

The mental status examination includes ✔Appearance and behavior, speech and language, mood, thoughts and perceptions, cognitive function, including memory, attention, information and vocabulary, calculations, abstract thinking and constructional ability. Dysarthria ✔Slurred speech, defective articulation Aphasia ✔disorder of language Receptive- (impaired comprehension with fluent speech) Expressive (with preserved comprehension and slow non-fluent speech)

• a person that can write a correct sentence does not have aphasia Dysphonia ✔impaired volume quality or pitch of voice Perceptions ✔Sensory awareness of objects in the environment and their interrelationships (external stimuli); also refers to internal stimuli such as dreams or hallucinations affect ✔a fluctuating pattern of observable behaviors that express subjective feelings or emotion that color the persons perception of the world. (Affect is to mood as weather is to climate) Lethargic ✔patients are drowsy but open their eyes and look at you , respond to questions and then fall asleep. Obtunded ✔patients open their eyes and look at you, but respond slowly and are somewhat confused.