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: Holding the infant's chin to his chest and knees to his abdomen during the procedure is not a correct action for the nurse to take. This position may cause spinal cord compression or respiratory distress in the infant. The nurse should position the infant on his side with his back arched and his head and knees flexed.

Choice B reason: Placing the infant in an infant seat for 2 hr following the procedure is not a correct action for the nurse to take. This position may increase the intracranial pressure and cause headaches or vomiting in the infant. The nurse should keep the infant flat or slightly elevated for 4 to 6 hr after the procedure.

Choice C reason: Keeping the infant NPO for 6 hr prior to the procedure is not a correct action for the nurse to take. This may cause dehydration or hypoglycemia in the infant. The nurse should follow the provider's orders for fasting, which are usually 2 to 4 hr for clear liquids and 4 to 6 hr for solids.

Choice D reason: Applying a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure is a correct action for the nurse to take. This is a topical anesthetic that can reduce the pain and discomfort of the needle insertion. The nurse should apply the cream to the lower back and cover it with an occlusive dressing.

A. The child has not had a bowel movement for 5 days. B. The child is crying and clinging to the guardian. C. The child has a temperature of 38.8°C (101.9°F) tympanic. D. The insertion site of the central line catheter is erythematous with a scant amount of purulent drainage.

Correct Answer is D

Explanation

Choice A reason: The child has acute lymphoblastic leukemia (ALL) and is receiving chemotherapy and steroids, which can cause constipation. The nurse should monitor the child's bowel function and provide interventions such as fluids, fiber, and laxatives as prescribed, but this is not an urgent finding.

Choice B reason: The child is in the induction phase of treatment for ALL, which can be stressful and frightening for the child and the family. The child's crying and clinging behavior indicates anxiety and fear, which are normal reactions. The nurse should provide emotional support and education to the child and the guardian, but this is not an urgent finding.

Choice C reason: The child has a fever, which is a common side effect of chemotherapy and steroids. The nurse should assess the child for other signs of infection, administer antipyretics as prescribed, and monitor the child's vital signs, but this is not an urgent finding.

Choice D reason: The child has a double-lumen central line catheter in the left chest wall, which is a potential source of infection. The erythema and purulent drainage at the insertion site indicate that the child has a local infection, which can spread to the bloodstream and cause sepsis. This is a life-threatening complication that requires immediate attention and treatment. The nurse should report this finding to the provider, obtain blood cultures, and administer antibiotics as prescribed.

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