A nurse is obtaining the length and weight of a 6-month-old infant.
Which of the following actions should the nurse take? (Select all that apply.)
Ensure the scale is balanced prior to use
Place a disposable covering on the scale
Use a stadiometer to measure the infant
Weigh the infant in a diaper
Correct Answer : A,B,D,E
E. The nurse should ensure the scale is balanced prior to use [A], place a disposable covering on the scale [B], weigh the infant in a diaper [D], and measure the infant from the crown of the head to the heels of the feet [E].
Choice C is incorrect because a stadiometer is used to measure standing height and is not appropriate for measuring the length of an infant who cannot stand.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Placing traction weights so they touch the head of the bed disrupts the effectiveness of the traction system. Skeletal traction relies on a continuous pulling force to maintain proper alignment of the fractured femur. If the weights are resting on any surface, the force is interrupted, which can lead to complications such as malunion or delayed healing. The weights must hang freely at all times to ensure therapeutic benefit.
Choice B reason:
Isometric exercises are beneficial for maintaining muscle tone and promoting circulation during immobilization. However, while this is a supportive intervention, it is not the most critical or immediate nursing action in the context of skeletal traction. Encouraging exercises every 8 hours is appropriate, but it does not directly address the most urgent or discomfort-related aspect of care.
Choice C reason:
Pin care is a routine but potentially painful procedure associated with skeletal traction. Administering pain medication beforehand is a priority nursing action because it ensures client comfort, reduces anxiety, and promotes cooperation during the procedure. This intervention reflects both compassionate care and adherence to best practices in pain management and infection prevention.
Choice D reason:
Repositioning a client in skeletal traction must be done with extreme caution to avoid disrupting the traction setup. Assisting the client to shift position every 4 hours may inadvertently alter the alignment or tension of the traction apparatus. While pressure injury prevention is important, repositioning must be coordinated carefully and is not the most appropriate standalone action in this context.
Correct Answer is B
Explanation
During pregnancy, a woman needs to increase her caloric intake by approximately 300 extra calories per day.
These extra calories should come from a balanced diet of protein, fruits, vegetables, and whole grains.
Choice A is incorrect because adding an additional 500 calories/day by drinking milkshakes is not a healthy way to increase caloric intake during pregnancy.
Choice C is incorrect because doubling caloric intake is not necessary during pregnancy.
Choice D is incorrect because while it is important to watch caloric intake during pregnancy, it is also important to increase caloric intake by approximately 300 extra calories per day.
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