Exhibits
A nurse is collecting data from a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Teeth
Weight
Speech
Temperature
The Correct Answer is C
A. Teeth: It is typical for infants to start getting their first teeth between 6 and 10 months. The infant in this scenario already has two lower central incisors, which is normal and does not need to be reported.
B. Weight: The infant's weight of 7.26 kg (16 lb) is within the expected range for a 6-month-old. Infants typically double their birth weight by 5 to 6 months of age, and this infant has almost reached that milestone, so the weight is not a concern.
C. Speech: By 6 months, most infants begin to make cooing sounds and may start attempting to imitate speech. That the infant makes cooing sounds but does not attempt to imitate speech is slightly concerning, as by 6 months, some infants are beginning to imitate speech sounds.
D. Temperature: The infant's temperature of 37.1°C (98.8°F) is within the normal range for an infant and does not indicate any issue. There is no need to report this finding to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Gently cleanse the surgical site with sterile gauze: direct vigorous cleansing of the palate surgical site with gauze is generally avoided to prevent disruption of sutures. Oral rinses or specific gentle cleaning methods may be prescribed, but direct gauze wiping is usually not recommended.
B. Offer a pacifier with glucose syrup: acifiers and any sucking on objects (including straws, spoons, or toys) are typically contraindicated after cleft palate repair because the sucking motion puts stress on the suture line and can disrupt healing.
C. Apply elbow immobilizers to both arms: Elbow immobilizers prevent the infant from bending their elbows and bringing their hands to their mouth or face, which could disrupt the surgical sutures, cause trauma, or introduce infection to the delicate palate repair.
D. Place the infant in a supine position: A semi-upright position is usually preferred to reduce pressure on the surgical site and prevent aspiration, rather than placing the infant flat on their back.
Correct Answer is B
Explanation
A. Explain the risks associated with the procedure: Explaining risks is important, but it's the provider's responsibility to provide detailed information about risks, benefits, and alternatives. The nurse should ensure understanding.
B. Determine the parent's understanding of the procedure: The nurse's role is to ensure the parent understands the procedure. This includes confirming comprehension and providing clarification if needed.
C. Provide detailed information about the procedure to the parent: The nurse may provide general information, but the detailed explanation of the procedure, risks, and benefits should come from the provider.
D. Discuss the benefits of the procedure: Discussing benefits is part of informed consent, but it should be explained by the provider. The nurse’s role is ensuring understanding, not providing detailed explanations.
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