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.)
Balance the scale to 0 prior to use.
Use a stadiometer to measure the infant.
Place a disposable covering on the scale.
Weigh the infant in a diaper.
Measure the infant from crown of the head to the heels of feet.
Correct Answer : A,C,E
Choice A reason: Balancing the scale to 0 prior to use is a correct action for the nurse to take. This ensures that the scale is accurate and does not include any extra weight from the scale itself or any objects on it.
Choice B reason: Using a stadiometer to measure the infant is not a correct action for the nurse to take. A stadiometer is a device that measures the height of a standing person. It is not suitable for measuring the length of an infant who cannot stand. The nurse should use a measuring board or a tape measure to measure the infant's length.
Choice C reason: Placing a disposable covering on the scale is a correct action for the nurse to take. This prevents the transmission of germs or dirt from the scale to the infant or vice versa. It also protects the scale from any urine or stool that the infant may produce during the weighing.
Choice D reason: Weighing the infant in a diaper is not a correct action for the nurse to take. A diaper can add extra weight to the infant's measurement and affect the accuracy of the result. The nurse should weigh the infant without any clothing or diaper.
Choice E reason: Measuring the infant from crown of the head to the heels of feet is a correct action for the nurse to take. This is the standard method of measuring the length of an infant. The nurse should place the infant on a flat surface, align the head with the top of the measuring board or tape measure, and extend the legs fully. The nurse should then read the measurement at the bottom of the infant's feet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The onset of low blood glucose, or hypoglycemia, usually occurs rapidly and can be triggered by skipping meals, exercising too much, or taking too much insulin. The nurse should teach the parents to recognize the signs and symptoms of hypoglycemia and how to treat it promptly.
Choice B reason: Feeling shaky is one of the common signs of low blood glucose, along with hunger, sweating, dizziness, confusion, and irritability. The nurse should teach the parents to check the child's blood glucose level and give him a fast-acting carbohydrate, such as juice, candy, or glucose tablets, if it is below 70 mg/dL.
Choice C reason: Sweating can occur with low blood glucose, not high blood glucose, or hyperglycemia. Hyperglycemia can cause symptoms such as thirst, frequent urination, dry mouth, blurred vision, and fatigue. The nurse should teach the parents to monitor the child's blood glucose level regularly and adjust his insulin dose, diet, and exercise accordingly.
Choice D reason: Nausea and vomiting can occur with high blood glucose, especially if it leads to diabetic ketoacidosis, a serious complication of diabetes. Diabetic ketoacidosis can also cause abdominal pain, fruity breath, rapid breathing, and coma. The nurse should teach the parents to seek emergency medical attention if the child has these symptoms.
Correct Answer is A
Explanation
Choice A reason: Rice is a suitable food choice for a child who has celiac disease, as it is a gluten-free grain that does not cause inflammation or damage to the small intestine. Rice can provide carbohydrates, fiber, and vitamins for the child's nutrition.
Choice B reason: Rye is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Rye can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Choice C reason: Wheat is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Wheat can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Choice D reason: Barley is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Barley can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
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