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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Selecting a catheter that fits snugly is important for proper suctioning, but it is more important to ensure the catheter is the correct size for the infant’s tracheostomy tube and airway.

B. Instilling saline prior to suctioning is generally not recommended unless specified by the healthcare provider, as it can increase the risk of aspiration and discomfort.

C. Suctioning should be done in short 3 to 4 second increments to avoid injury to the airway and to minimize the infant’s distress. Prolonged suctioning can cause hypoxia and trauma to the mucosa.

D. Suctioning for infants with tracheostomies requires sterile technique to prevent infection, not clean technique.

A. Haemophilus influenzae type b B. Hepatitis A C. Rotavirus D. Human papillomavirus

Correct Answer is D

Explanation

A. Haemophilus influenzae type b (Hib) vaccination is typically given to infants and toddlers, not to children who are 11 years old. The child would likely have already received this vaccine as part of their early childhood immunizations.

B. Hepatitis A vaccination is recommended for children, but it is typically given earlier in childhood (around 1 year of age), and would not be given at 11 years old unless it is part of a catch-up schedule.

C. Rotavirus vaccination is given to infants, and by the age of 11, the child should have completed the recommended series.

D. The Human papillomavirus (HPV) vaccine is recommended for children ages 11 to 12 years, making it appropriate for this child. The nurse should plan to administer the HPV vaccine as part of routine immunizations for this age group.

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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?

Nursing Test Bank

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