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 C
Explanation
Choice A reason:
Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.
Choice B reason:
The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.
Choice C reason:
Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.
Choice D reason:
Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.
Correct Answer is B
Explanation
Choice A reason:
Pneumonia is typically transmitted through respiratory droplets, and standard precautions are sufficient for preventing its spread.
Choice B reason:
Correct. Tuberculosis (TB) is an infectious disease that requires contact precautions. This helps prevent the spread of Mycobacterium tuberculosis, the bacteria that cause TB.
Choice C reason:
Haemophilus influenzae type B disease is primarily transmitted through respiratory droplets, so standard precautions are generally sufficient.
Choice D reason:
Respiratory syncytial virus (RSV) is primarily transmitted through respiratory droplets, so standard precautions are generally sufficient. However, in some cases, droplet precautions may be recommended for infants and young children with severe RSV infections.
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