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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: This is not a correct instruction for the nurse to include in the teaching. The Pavlik harness is a device that holds the infant's hips in a flexed and abducted position to allow the femoral head to fit into the acetabulum. The harness should not be removed by the parents, as this may interfere with the treatment and cause complications. The nurse should instruct the parents to sponge bathe the infant while wearing the harness.

Choice B reason: This is not a correct instruction for the nurse to include in the teaching. The length of the straps of the Pavlik harness should not be adjusted by the parents, as this may affect the alignment and stability of the infant's hips. The nurse should instruct the parents to bring the infant to the provider's office regularly for check-ups and adjustments of the harness.

Choice C reason: This is not a correct instruction for the nurse to include in the teaching. Massaging the infant's skin under the straps of the Pavlik harness may cause irritation, friction, or pressure on the skin, which may lead to skin breakdown or infection. The nurse should instruct the parents to keep the infant's skin clean and dry, and to check for any signs of redness, swelling, or drainage.

Choice D reason: This is a correct instruction for the nurse to include in the teaching. Placing the diaper under the straps of the Pavlik harness prevents the diaper from interfering with the position and function of the harness. The nurse should instruct the parents to change the diaper frequently and to avoid using bulky or cloth diapers.

A. The quality of food I provide him is more important than the quantity. B. I should expect him to have an increased appetite. C. Because he is such a picky eater, I will give him one of my vitamins each day. D. His average daily intake should be about 3,000 calories.

Correct Answer is A

Explanation

Choice A reason: This statement shows that the parents understand that toddlers need a balanced diet that includes a variety of foods from different food groups. The quality of food is more important than the quantity, as toddlers may have erratic eating patterns and may not consume large amounts of food at one time.

Choice B reason: This statement is incorrect, as toddlers typically have a decreased appetite compared to infants. This is due to their slower growth rate and increased interest in other activities. Parents should not force their toddlers to eat more than they want, but rather offer them healthy snacks and meals throughout the day.

Choice C reason: This statement is incorrect, as toddlers do not need vitamin supplements unless they have a specific deficiency or medical condition. Giving vitamins to a picky eater may not address the underlying causes of their food preferences, such as texture, taste, or appearance. Parents should encourage their toddlers to try new foods and avoid using food as a reward or punishment.

Choice D reason: This statement is incorrect, as toddlers do not need 3,000 calories per day. The average daily caloric intake for a toddler is about 1,000 to 1,400 calories, depending on their age, weight, and activity level. Parents should not overfeed their toddlers or give them high-calorie foods that may lead to obesity or malnutrition.

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