A nurse is preparing to obtain the length and weight of a 6-month-old infant during a well- child visit. Which of the following actions should the nurse plan to take? (Select all that apply.)
Obtain the infant's weight with their diaper on.
Place a stadiometer on the top of the infant's head to measure their length.
Ensure the scale is balanced to "0" before weighing the infant.
Cover the scale with a clean sheet of paper..
Measure the infant's length from the crown of the head to the heels of the feet.
Correct Answer : C,D,E
Choice A reason:
Obtaining the infant's weight with their diaper on should be avoided as this can alter the result.
Choice B reason:
Placing a stadiometer on the top of the infant's head to measure their length can harm or distress the infant.
Choice C reason:
Ensuring the scale is at 0 is important in obtaining an accurate weight Choice D reason:
Covering the scale with paper is recommended for hygiene purposes
Choice E reason:
This method provides an accurate measurement of the infant's length.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Discontinuing antibiotics when the fever has resolved is not an appropriate instruction for a child with infective endocarditis. The full course of antibiotics should be completed.
Choice B reason:
While antibiotics can have side effects, splinter hemorrhages under the child's nails are not a common side effect of antibiotic use for infective endocarditis.
Choice C reason:
Obtaining prophylactic antibiotics for family members is not a standard practice for infective endocarditis.
Choice D reason:
This statement is correct. Antibiotics are needed prior to certain dental procedures for children with infective endocarditis to prevent bacterial endocarditis.
Correct Answer is B
Explanation
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
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