A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night.
Which finding is most significant in planning care for this family?
The mother states the baby is irritable during feedings.
The mother is a single parent and lives with her parents.
The infant's formula has been changed twice.
The diaper area shows severe skin breakdown.
The Correct Answer is D
The most significant finding in planning care for this family is that the infant's diaper area shows severe skin breakdown. Severe skin breakdown in the diaper area can be a sign of diaper rash or other skin irritation, which can cause discomfort and disrupt the infant's sleep. Addressing this issue can help improve the infant's comfort and promote beter sleep. The other options (A, B, and C) may also be relevant, but severe skin breakdown in the diaper area is the most significant finding in this situation.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should include rice in the list of allowed foods for a child who is newly diagnosed with celiac disease. Rice is a gluten-free grain and is safe for individuals with celiac disease to consume. Rye, oats, and barley all contain gluten and should be avoided by individuals with celiac disease. However, some individuals with celiac disease may be able to tolerate oats that are certified gluten-free and not contaminated with other gluten-containing grains.

Correct Answer is C
Explanation
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.

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