A nurse in the well child clinic obtained the height, weight, and head circumference of a 1-year-old child. The nurse documents the findings on a growth chart and notes that the child is below the 5th percentile for both height and weight. Which of the following actions should the nurse perform?
Notify the primary care provider immediately of this assessment finding.
Report the parents to the local authorities for potential child neglect.
Compare the findings on the current growth chart to previous growth charts completed on the child.
Ask the parents to provide a detailed list of the child's usual diet in a 24-hour period.
The Correct Answer is C
Rationale:
A. Notify the primary care provider immediately of this assessment finding: Immediate notification is not necessary unless there are additional acute concerns such as signs of illness or failure to thrive with rapid decline. Growth trends over time are more informative than a single measurement when evaluating potential growth issues.
B. Report the parents to the local authorities for potential child neglect: Being below the 5th percentile alone does not indicate neglect. Further assessment, including growth trends, dietary history, and developmental status, is required before considering reporting to authorities.
C. Compare the findings on the current growth chart to previous growth charts completed on the child: Evaluating growth trends over time is essential to determine whether the child’s growth pattern is consistent or showing deceleration. This helps identify potential chronic issues, nutritional deficiencies, or underlying medical conditions that require intervention.
D. Ask the parents to provide a detailed list of the child's usual diet in a 24-hour period: Dietary history can provide useful information, but it should be part of a broader assessment after reviewing growth trends. A single 24-hour recall may not accurately reflect the child’s typical nutritional intake and should not be the first step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Tachypnea and diaphoresis with feeding, poor weight gain, and irritability: Tachypnea and sweating during feeds indicate increased cardiac workload, poor weight gain reflects inadequate nutrition due to fatigue, and irritability can result from decreased perfusion and hypoxia. Caregivers should be able to identify these signs promptly.
B. Cough, edema, and irregular heart rate: While cough and edema may occur in older children or adults with heart failure, they are less specific in infants. Irregular heart rate can indicate arrhythmia but is not the most sensitive early marker of heart failure worsening in this age group.
C. Abdominal pain, poor appetite, and cough: Poor appetite may be present, but abdominal pain is not a typical early sign of infant heart failure. Cough is more often associated with respiratory infections rather than early heart failure.
D. Bradycardia, rapid weight gain, and irritability: Bradycardia is not an early sign of worsening heart failure in infants; it may indicate severe hypoxia or advanced decompensation. Rapid weight gain could suggest fluid retention, but in combination with bradycardia, it reflects a more severe state rather than an early warning.
Correct Answer is ["6.3"]
Explanation
Calculation:
Ordered Dose: 15 mg/kg
Child's Weight: 13.5 kg
Available Concentration: 160 mg per 5 mL
- Calculate the Total Dose in Milligrams (mg)
Total Dose (mg) = 15 mg/kg × 13.5 kg
= 202.5 mg
- Calculate the Volume to Administer in Milliliters (mL)
Volume (mL) = (Ordered Dose (D) / Available Dose (H)) × Quantity (Q)
= (202.5 mg / 160 mg) × 5 mL
= 1.265625 × 5 mL
= 6.328 mL
- Round to the Nearest Tenth
= 6.3
Answer: 6.3 mL
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