A nurse is collecting data from a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data)
Gross motor skills
Temperature
weight
Feeding habits
The Correct Answer is C
A. Gross motor skills: Rolling from abdomen to back, playing with feet, smiling responsively, and turning toward sounds are expected developmental milestones at 6 months of age. These findings indicate appropriate gross motor, social, and sensory development.
B. Temperature: A temperature of 37.4° C (99.3° F) is within the normal range for an infant. This finding does not suggest infection or illness and does not require provider notification.
C. Weight: At 6 months of age, an infant is expected to have approximately doubled their birth weight. This infant weighed 3.6 kg at birth and currently weighs 5.9 kg, which suggests inadequate weight gain and should be reported for further evaluation.
D. Feeding habits: Breastfeeding combined with small amounts of cereal and fruit three times daily is appropriate for a 6-month-old infant. There is no indication from the feeding history alone that intake is inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You need to talk to a therapist about how you're feeling.": Referring to a therapist may be appropriate later if needed, but this response does not validate the client’s feelings or provide immediate emotional support. It may also make the client feel dismissed.
B. "Wouldn't worry about it if I were you. You'll be a good mother.": This response minimizes the client’s feelings and provides reassurance rather than acknowledging their ambivalence. Minimization can inhibit open communication and does not promote therapeutic rapport.
C. "Why do you feel that way if you've been trying to get pregnant?": Asking "why" can come across as judgmental or confrontational and may make the client defensive. It does not provide support or normalize the experience of mixed emotions.
D. "Many women experience feelings of ambivalence during pregnancy.": This response normalizes the client’s feelings, validating their experience without judgment. It encourages open discussion and helps the client feel understood, which is a key aspect of therapeutic communication.
Correct Answer is D
Explanation
A. Room number of the client: Room numbers can change frequently and do not uniquely identify a client. Relying on room number alone increases the risk of medication errors and is not considered a safe identifier.
B. Name of the client's provider: The provider’s name does not verify the client’s identity and cannot be used to ensure medications are given to the correct individual. It may be relevant for contacting regarding prescriptions but not for client identification.
C. Client’s full medical diagnosis: The diagnosis provides clinical context but is not unique to the client and cannot confirm identity. Multiple clients may share the same diagnosis, so it is insufficient for safe medication administration.
D. Client's telephone number: Using personal identifiers such as telephone number, along with at least one other identifier (e.g., full name, date of birth, or medical record number), helps accurately verify the client’s identity. This reduces the risk of medication errors and ensures safe administration.
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