A nurse is planning to collect data from an 11-month-old infant who has failure to thrive. Which of the following findings should the nurse expect?
Weight above the 10th percentile
Makes eye contact with others
Poor muscle tone
Stranger anxiety
The Correct Answer is C
A. Weight above the 10th percentile would not be expected in an infant with failure to thrive. Infants with failure to thrive typically exhibit weight below the 5th percentile due to insufficient caloric intake or absorption.
B. Making eye contact with others is a normal developmental milestone at 11 months and would not be expected to be impaired in a child with failure to thrive.
C. Poor muscle tone is a common finding in infants with failure to thrive, as malnutrition and inadequate nourishment can affect the development of muscle strength and coordination.
D. Stranger anxiety is a typical developmental stage at 11 months, but it is not associated with failure to thrive. Infants with failure to thrive may exhibit developmental delays, but stranger anxiety is not a primary concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Repositioning the pulse oximetry probe every 2 hours is unnecessary unless there is a concern about skin integrity or the accuracy of the reading. Continuous monitoring generally requires the probe to be in place for longer periods.
B. Taping the wire to the palm of the hand is not recommended because it may cause skin irritation or pressure injury. The sensor should be placed on a finger or toe, where blood flow is easily accessible.
C. Applying the sensor to the index fingernail is not ideal. Pulse oximetry is most accurate when applied to a finger or toe, but not directly on the nail itself. It should be placed on the skin near the nail.
D. Warming the skin prior to probe placement is recommended to ensure better circulation and accurate pulse oximetry readings, especially in children or individuals with poor peripheral circulation.
Correct Answer is D
Explanation
A. Barrel chest is not a typical finding in RSV. It is more commonly associated with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD) or cystic fibrosis.
B. Clubbing of the fingers is usually seen in chronic respiratory conditions like cystic fibrosis, but it is not a typical manifestation of RSV, which is usually acute.
C. Vesicles on the trunk are characteristic of viral infections such as chickenpox, not RSV. RSV primarily affects the respiratory system, causing symptoms like wheezing and coughing.
D. Rhinorrhea, or a runny nose, is a common early symptom of RSV. RSV often starts with cold-like symptoms, including nasal congestion, rhinorrhea, and cough, before progressing to more severe respiratory distress.
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