A nurse is assisting in the care of a 6 year old child who preoperative for repair of a fractured femur.

Exhibits

For each finding click to specify whether the finding indicates no change in the child's condition or is a sign of potential worsening condition.

A. Place a stadiometer on the top of the infant's head to measure their length is incorrect. For infants, length is measured while they are lying down, not standing. A stadiometer is typically used for measuring standing height in older children and adults.

B. Measure the infant's length from the crown of the head to the heel is correct. When measuring the length of an infant, the child should be lying down, and the measurement should be taken from the crown of the head to the heel using a length board or measuring tape.

C. Cover the scale with a clean sheet of paper is necessary for weighing an infant. This helps maintain infection control and keeps the infant comfortable.

D. Obtain the infant's weight with the diaper on is incorrect. For the most accurate weight measurement, the diaper should be removed before weighing the infant. A diaper can add extra weight and affect the measurement.

E. Ensure the scale is balanced before weighing is correct. Before obtaining the weight, the nurse should verify that the scale is balanced and zeroed to ensure accurate measurements.

A. A 4-year-old preschooler who has a rivalry with their siblings is incorrect. Sibling rivalry is a normal part of child development and does not indicate abuse or neglect that would require reporting.

B. A 24-month-old toddler who experiences occasional incontinence is incorrect. Occasional incontinence is developmentally appropriate for a 2-year-old and is not a concern for mandatory reporting.

C. A 6-month-old infant who has a spiral fracture to a lower extremity is correct. Spiral fractures in non-ambulatory infants are highly suspicious for non-accidental trauma (child abusE. and should be reported to local authorities for further investigation. These fractures are often caused by twisting forces rather than accidental injuries.

D. A 9-month-old infant who has been exposed to bedbugs and has cellulitis is incorrect. While bedbug exposure and cellulitis require medical treatment and possibly social support, they do not necessarily indicate abuse or neglect that mandates reporting.