The correct answer is B.

The nurse cares for a 1-month-old infant in the clinic. During the assessment of the infant, which will the nurse expect to observe?

  • 1. The anterior fontanel is closed.
  • 2. The grasp reflex is strong bilaterally.
  • 3. The child has gained 1 to 3 ounces per week.
  • 4. The child has no head lag when pulled into the sitting position.

Explanation:

  • 1. The anterior fontanel closes at 9 to 18 months.
  • 2. CORRECT - Grasping occurs as a reflex during the first 2 to 3 months of life. Grasp reflex should be absent by 3 to 4 months. Hands are predominantly closed during the first month of life.
  • 3. Weight gain is approximately 5 to 7 ounces weekly during the first 6 months of life.
  • 4. This is expected when a 1-month-old is pulled from a lying to a sitting position. Head lag should be absent at 4 to months.

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