A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH).
Which of the following strategies should the nurse implement to promote the infant's growth and development?
Allow the infant to stand in the crib.
Provide a small electronic toy.
Tie colorful latex balloons to the side of the crib.
Change the infant's diaper as soon as soiling occurs.
None
None
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: Encouraging the infant to stand in the crib while in a cast for developmental dysplasia of the hip (DDH) supports gross motor development and maintains neuromuscular stimulation. Standing promotes proprioceptive input, strengthens postural muscles, and supports bone mineralization through weight-bearing. Infants in hip spica casts or orthotic devices can safely stand with supervision, preserving developmental milestones. Normal serum calcium ranges from 8.5 to 10.5 mg/dL, and mechanical loading enhances osteoblastic activity and skeletal growth.
Choice B rationale: While electronic toys offer sensory stimulation, they do not adequately support gross motor development in infants with DDH. At 10 months, infants require opportunities for vertical positioning and weight-bearing to stimulate vestibular and musculoskeletal systems. Passive play with electronic toys may delay motor milestones such as cruising and standing. Developmental progress depends on integrated sensory-motor experiences, and reliance on sedentary toys may limit engagement of core and lower limb musculature.
Choice C rationale: Latex balloons pose a significant safety hazard due to the risk of aspiration and suffocation. When burst, latex fragments can occlude the airway, especially in infants with underdeveloped protective reflexes. The tracheal diameter in infants averages 4 to 5 mm, making obstruction by balloon fragments potentially fatal. Additionally, latex exposure may trigger allergic reactions, particularly in atopic individuals. The American Academy of Pediatrics strongly advises against latex balloon use in children under 8 years.
Choice D rationale: Prompt diaper changes are essential for skin integrity, especially under a cast where moisture retention can lead to maceration and infection. However, this action does not directly promote growth and development. It is a hygiene measure that prevents irritant contact dermatitis and secondary infections such as Candida albicans. Normal skin pH ranges from 4.5 to 5.5, and prolonged exposure to urine and feces elevates pH, disrupting the acid mantle. While necessary, it lacks developmental stimulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: Pediculosis capitis.
Choice D rationale: Pediculosis capitis is an infestation of head lice, which causes symptoms such as white flakes that do not brush off the hair easily and a rash on the back of the neck. These symptoms are due to the lice feeding on the scalp and laying eggs (nits), which can cause itching and irritation.
Choice A rationale: Folliculitis is an inflammation of the hair follicles, typically caused by bacterial or fungal infections. While it can cause a rash, it is not characterized by white flakes in the hair.
Choice B rationale: Tinea capitis, also known as ringworm of the scalp, is a fungal infection that causes scaly, itchy patches on the scalp. It may lead to hair loss in the affected areas, but it does not typically cause white flakes that do not brush off the hair.
Choice C rationale: Impetigo contagiosa is a highly contagious bacterial skin infection that causes blisters or sores on the skin. It does not involve white flakes in the hair and primarily affects exposed skin rather than the scalp.
Correct Answer is B
Explanation
Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration fluids, is not necessary because the child’s urine output is within the normal range.
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