A nurse is planning to assess a 10 month-old infant and bases the assessment on which rationale?
Begin with taking all the vital signs.
Use the Faces scale to rate their pain
Start with less intrusive methods.
Be systematic and go in head to toe order.
The Correct Answer is C
A. Begin with taking all the vital signs.
This is not the preferred approach for assessing a 10-month-old infant. Vital signs may be intimidating and intrusive, and starting with less invasive methods is generally recommended.
B. Use the Faces scale to rate their pain.
The Faces scale is typically used for older children who can express themselves verbally. It may not be suitable for a 10-month-old infant.
C. Start with less intrusive methods.
This is the correct choice. Beginning with less intrusive methods, such as observation and gentle interactions, helps build trust and ensures the infant is comfortable during the assessment.
D. Be systematic and go in a head-to-toe order.
While being systematic is important, starting with less intrusive methods and adapting the approach based on the infant's response is generally more appropriate than a strict head-to-toe order.
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Related Questions
Correct Answer is A
Explanation
A. Autonomy.
The ethical/moral principle represented in this situation is autonomy. Autonomy refers to the respect for an individual's right to make their own decisions and choices about their own life and well-being. In this case, the parent expressing second thoughts about the child's surgery reflects a reconsideration of the decision, and the nurse's action of calling the surgeon respects the parent's autonomy by seeking further discussion and clarification.
B. Fidelity
Fidelity refers to the principle of faithfulness, loyalty, and keeping promises. While it is important in the healthcare context, the scenario does not involve a breach of fidelity.
C. Equality
Equality relates to the fair and just treatment of individuals. In this scenario, the primary focus is on the parent's autonomy and the reconsideration of the elective surgery, rather than issues of equality.
D. Justice
Justice involves the fair distribution of benefits and burdens in society. The scenario does not directly relate to justice but is more aligned with the principle of autonomy as the parent reconsiders the decision about the child's surgery.
Correct Answer is A
Explanation
A. 21 pounds: This is the correct answer. The general guideline is that infants tend to triple their birth weight by the age of 12 months. If the infant weighed 7 pounds at birth, tripling that weight would be 21 pounds.
B. 14 pounds: This weight would not be consistent with the expected weight gain of a healthy infant by 12 months. It's too low based on the tripling guideline.
C. 25 pounds: This weight would be higher than expected based on the tripling guideline. It's not a typical weight for a healthy 12-month-old who had a birth weight of 7 pounds.
D. 10 pounds: This weight would be lower than the expected weight gain. A 12-month-old who started at 7 pounds should have gained more weight by this age.
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