A nurse is planning to collect data from an 11-month-old infant who has failure to thrive. Which of the following findings should the nurse expect?
Weight above the 10th percentile
Makes eye contact with others
Poor muscle tone
Stranger anxiety
The Correct Answer is C
A. Weight above the 10th percentile would not be expected in an infant with failure to thrive. Infants with failure to thrive typically exhibit weight below the 5th percentile due to insufficient caloric intake or absorption.
B. Making eye contact with others is a normal developmental milestone at 11 months and would not be expected to be impaired in a child with failure to thrive.
C. Poor muscle tone is a common finding in infants with failure to thrive, as malnutrition and inadequate nourishment can affect the development of muscle strength and coordination.
D. Stranger anxiety is a typical developmental stage at 11 months, but it is not associated with failure to thrive. Infants with failure to thrive may exhibit developmental delays, but stranger anxiety is not a primary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Aspirin is contraindicated for children due to the risk of Reye's syndrome, a potentially fatal condition associated with aspirin use in children under the age of 18.
B. Administering acetaminophen at this frequency could result in overdose or liver damage, especially in children. Acetaminophen should be given at appropriate intervals (usually every 4–6 hours) as per the prescribed dosage.
C. Lowering the temperature of the room can help reduce the child’s fever without overcooling. A comfortable room temperature helps to prevent further heat retention and promotes the child's comfort.
D. An ice bath can cause shivering, which could raise the body temperature and cause additional harm. It is not recommended for fever reduction in children.
Correct Answer is D
Explanation
A. Increased blood pressure is typically not associated with dehydration. In fact, dehydration often causes hypotension or low blood pressure, especially in severe cases.
B. Distended jugular veins are usually a sign of fluid overload or heart failure, not dehydration. In dehydration, the veins may appear flat due to decreased fluid volume.
C. A flat anterior fontanel is generally expected in a well-hydrated child. A sunken fontanel would indicate dehydration in infants and young toddlers.
D. Increased pulse (tachycardia) is a common sign of dehydration. As the body loses fluid, the heart compensates by increasing the heart rate to maintain adequate perfusion of organs.
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