Exhibits
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 C
Explanation
A. Weight loss: Weight loss is more commonly associated with dehydration or inadequate nutritional intake. In fluid overload, clients typically demonstrate weight gain due to excess fluid retention.
B. Decreased skin turgor: Decreased skin turgor is a sign of fluid volume deficit rather than excess. Fluid overload usually presents with edema and taut skin rather than reduced elasticity.
C. Crackles heard in the lungs: Crackles indicate fluid accumulation in the alveoli and are a classic sign of fluid overload. This finding suggests pulmonary congestion and requires prompt assessment and intervention.
D. Decreased blood pressure: Fluid overload is more likely to cause increased or normal blood pressure due to expanded intravascular volume. Decreased blood pressure is more consistent with hypovolemia or shock states.
Correct Answer is A
Explanation
A. Ask the family if they want to participate in postmortem care: Allowing the family to choose whether to participate respects their cultural, spiritual, and personal preferences. This promotes dignity for both the client and family and provides an opportunity for closure.
B. Let the head of the client's bed flat: The client’s head should typically be elevated slightly to prevent discoloration of the face and to maintain a natural appearance for viewing. Flat positioning can cause facial edema or pooling of blood, which may be distressing to the family.
C. Place medical equipment to the side of the client's bed: While removing or repositioning equipment can help create a more comfortable viewing environment, it is not the first or most essential step in preparing for postmortem care.
D. Remove the client's dentures to close their mouth: Dentures should usually be left in place to maintain the natural shape of the face unless instructed otherwise. Removing them can cause the mouth to appear sunken, which may be distressing to the family.
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