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 A
Explanation
A. The client: A married 17-year-old is considered emancipated in most states and has the legal authority to provide informed consent for their own medical care, including surgery. The nurse should obtain the client’s signature to confirm understanding and voluntary agreement.
B. The client's provider: The provider performs the procedure and is responsible for explaining the risks, benefits, and alternatives, but does not sign the consent on behalf of the client.
C. The client's partner: A spouse or partner does not have legal authority to consent for an emancipated minor unless specifically granted by law, so the partner’s signature is not required.
D. The client's caregiver: A parent or guardian would normally provide consent for a minor, but an emancipated minor has independent legal authority, making caregiver consent unnecessary in this scenario.
Correct Answer is B
Explanation
A. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements in a newborn typically help excrete bilirubin and reduce the risk of jaundice. Therefore, having multiple stools on the first day is actually protective rather than a risk factor.
B. “This is because your baby's liver is not yet efficient at breaking down red blood cells.”: Newborns naturally have an immature liver that is less efficient at conjugating and excreting bilirubin. This leads to an accumulation of unconjugated bilirubin in the blood, making a serum bilirubin test necessary to monitor for jaundice.
C. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding alone is not a contraindication nor an immediate reason to supplement. Breastfeeding jaundice can occur in some infants, but formula supplementation is not automatically required and should be based on assessment by the provider.
D. “Your baby is at a higher risk because they were born with congenital dermal melanocytosis.”: Congenital dermal melanocytosis (Mongolian spots) is a benign skin pigmentation and does not affect bilirubin metabolism.
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