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.
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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. Redness at the injection site is a common and mild reaction to vaccines. It does not typically require immediate medical intervention unless it worsens or is accompanied by more severe symptoms.
B. A temperature of 37.7° C (99.9° F) is a low-grade fever, which is a common, expected response after immunization. It is not a priority unless it increases significantly or is accompanied by other concerning symptoms.
C. Prolonged crying can sometimes occur after immunizations, but it is usually self-limited and resolves within a short period. If the crying is not excessive and does not indicate distress, it is generally not a priority concern.
D. Hives on the child’s neck could be a sign of an allergic reaction, such as anaphylaxis, which is a medical emergency. The nurse should immediately assess the child’s airway and provide necessary interventions, such as administering epinephrine, if required. This finding is the priority because it suggests a possible severe allergic response
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