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 D
Explanation
The correct answer is D) A child whose parents answer questions for the child.
Here is a detailed explanation for each choice:
Choice A reason:
A child who has a BMI indicating obesity: While obesity can be a concern for a child’s health, it is not a direct indicator of abuse. Obesity can result from various factors, including genetics, diet, and physical activity levels. It does not necessarily suggest that the child is experiencing abuse or neglect.
Choice B reason:
A child who has frequent visitors: Frequent visitors can indicate a strong support system and concern for the child’s well-being. It is not typically associated with abuse. In fact, children who are abused often have fewer visitors and less social support.
Choice C reason:
A child who uses the call light frequently: Frequent use of the call light may indicate that the child is seeking attention or has unmet needs, but it is not a specific indicator of abuse. Children may use the call light for various reasons, including anxiety, pain, or a need for reassurance.
Choice D reason:
A child whose parents answer questions for the child: This behavior can be a red flag for abuse. When parents consistently answer questions for the child, it may indicate that they are controlling the child’s communication and preventing them from speaking freely. This can be a sign of emotional abuse or manipulation.
Correct Answer is A
Explanation
Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
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