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 B
Explanation
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
Correct Answer is C
Explanation
Choice A reason:
Giving the infant a bottle immediately before bedtime can actually exacerbate gastroesophageal reflux, as lying down right after feeding can increase the likelihood of regurgitation.
Choice B reason:
Switching to a soy-based formula is not the first-line intervention for gastroesophageal reflux. Additionally, soy-based formulas are not recommended for all infants and should be used under specific circumstances.
Choice C reason:
This statement is correct. Keeping the infant at a 30° angle for 1 hour following each feeding can help reduce the likelihood of gastroesophageal reflux. This position helps gravity keep the stomach contents from flowing back up into the esophagus.
Choice D reason:
Limiting formula feedings to every 6 hours may not be appropriate for a 2-month-old infant, as they typically require more frequent feedings for proper growth and development.
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