Exam NCLEX-RN topic 4 question 117 discussion

Actual exam question from Test Prep's NCLEX-RN

Question #: 117
Topic #: 4

A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?

A. Hyperextension of the neck with evidence of pain on flexion
B. Holding the head to one side and pointing the chin toward the other side
C. Holding the head erect and in the midline when in a vertical position
D. Significant head lag when raised to a sitting position

Show Suggested Answer

Suggested Answer: D 🗳️
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.

by [deleted] at March 10, 2025, 6:49 a.m.

Comments

Submit Cancel

Currently there are no comments in this discussion, be the first to comment!