Asked by Leslie Teresa Medina on May 02, 2024
Verified
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response?
A) The infant shows no obvious response to the noise.
B) The infant shows a startle and acoustic blink reflex.
C) The infant turns his or her head to localize the sound.
D) The infant stops any movement, and appears to listen for the sound.
Startle
A quick, involuntary reaction or movement in response to a sudden, unexpected stimulus.
Clapping Hands
The action of striking the palms together to produce sound, often used as a means of showing approval or keeping rhythm.
Localize
The process of identifying or confining something (such as a condition or sensation) to a specific area or part of the body.
- Master the appropriate evaluation methods for patients presenting with conditions or complaints related to the ear in the nursing field.
Verified Answer
ZK
Zybrea KnightMay 07, 2024
Final Answer :
C
Explanation :
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. A 7-month-old infant should respond to noise. With a loud sudden noise, the nurse should notice the infant turning his or her head (not stopping any movement) to localize the sound and to respond to his or her own name.
Learning Objectives
- Master the appropriate evaluation methods for patients presenting with conditions or complaints related to the ear in the nursing field.