A nurse is assessing a 12-month-old infant who is brought to the clinic by the parents for a well-child visit. The nurse reviews the infant's health history and notes that the infant weighed 8 lb at birth. When assessing the infant's weight at this visit, the nurse would anticipate that the infant would weigh approximately how much at this time?

Answer and Explanation

The Correct Answer is C

A. 20 lbs: This is a plausible estimate. By 12 months, an infant's birth weight typically triples. Therefore, an 8 lb birth weight would approximately translate to 24 lbs at 12 months.

B. 32 lbs: This estimate is too high. If an infant's birth weight triples by 12 months, an 8 lb birth weight would not be expected to reach 32 lbs.

C. 24 lbs: An infant's weight usually triples by their first birthday. Therefore, an infant born weighing 8 lbs would be expected to weigh about 24 lbs at 12 months.

D. 16 lbs: This is an underestimate. An 8 lb infant would double their birth weight by about 4 to 6 months, and by 12 months, they would typically have tripled their birth weight to around 24 lbs.

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Correct Answer is A

Explanation

A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.

B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.

C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.

D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.

A. Ongoing assessment B. Focused assessment C. Emergency assessment D. Comprehensive assessment

Correct Answer is A

Explanation

A. Ongoing assessment: Ongoing assessments are continuous evaluations performed throughout the nurse's shift to monitor the client's status, response to interventions, and to adjust the care plan as needed.

B. Focused assessment: A focused assessment is targeted on a specific problem or area of concern, rather than a general or comprehensive evaluation.

C. Emergency assessment: An emergency assessment is rapid and focuses on identifying life-threatening conditions or urgent needs. It is not a routine, ongoing assessment.

D. Comprehensive assessment: A comprehensive assessment is an in-depth evaluation of the client's overall health status, usually performed upon admission or during initial evaluation. It is not typically repeated throughout the shift.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

Correct Answer is A

Explanation

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?

Correct Answer is A

Explanation

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening?

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

Which type of play is most typical of the toddler stage?

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

When assessing the abdomen, which assessment technique is used last?