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 A
Explanation
A. Place a pillow under the child's head: Protecting the head prevents injury from impact with the floor during the seizure. Using a pillow or folded blanket cushions the head while allowing the seizure to run its course safely.
B. Restrain the child's upper extremities: Restraining movements during a seizure can cause fractures, dislocations, or soft tissue injury. The nurse should allow the seizure to occur naturally while ensuring the environment is safe.
C. Place a padded tongue blade in the child's mouth: Inserting any object into the mouth is unsafe and can cause dental injury, aspiration, or airway obstruction. Current guidelines advise against this practice.
D. Turn the child onto their back: Placing a child supine during a seizure increases the risk of airway obstruction and aspiration. The recommended position is lateral (side-lying) to maintain airway patency and allow secretions to drain.
Correct Answer is B
Explanation
A. Hematuria: Hematuria is not a typical adverse effect of methylergonovine. This medication primarily affects uterine smooth muscle and vascular tone, so urinary complications are uncommon.
B. Elevated blood pressure: Methylergonovine is a potent vasoconstrictor, which can lead to hypertension. Monitoring blood pressure is essential because severe elevations can increase the risk of stroke or cardiac complications, especially in clients with preexisting hypertension.
C. Uterine relaxation: Methylergonovine promotes uterine contraction, not relaxation. Uterine relaxation would be contrary to the intended therapeutic effect of preventing or controlling postpartum hemorrhage.
D. Diarrhea: Gastrointestinal upset, including nausea, vomiting, or diarrhea, can occur but is less common and typically mild. Blood pressure changes are the primary adverse effect requiring close monitoring.
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