A nurse is preparing to obtain the length and weight of a 6-month-old infant during a well- child visit. Which of the following actions should the nurse plan to take? (Select all that apply.)
Obtain the infant's weight with their diaper on.
Place a stadiometer on the top of the infant's head to measure their length.
Ensure the scale is balanced to "0" before weighing the infant.
Cover the scale with a clean sheet of paper..
Measure the infant's length from the crown of the head to the heels of the feet.
Correct Answer : C,D,E
Choice A reason:
Obtaining the infant's weight with their diaper on should be avoided as this can alter the result.
Choice B reason:
Placing a stadiometer on the top of the infant's head to measure their length can harm or distress the infant.
Choice C reason:
Ensuring the scale is at 0 is important in obtaining an accurate weight Choice D reason:
Covering the scale with paper is recommended for hygiene purposes
Choice E reason:
This method provides an accurate measurement of the infant's length.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
A sodium level of 140 mEq/L is within the normal range.
Choice B reason:
An iron level of 100 mcg/dL is within the normal range.
Choice C reason:
A calcium level of 9 mg/dL is within the normal range.
Choice D reason:
Correct. A hemoglobin level of 8 g/dL is lower than the normal range for a preschooler and should be reported to the provider for further evaluation. This may indicate anemia, which requires assessment and potential intervention.
Correct Answer is C
Explanation
Choice A reason:
A subdural hematoma may not directly affect the fontanels. Depressed fontanels can be a sign of dehydration or other underlying conditions, but they are not specifically associated with a subdural hematoma.
Choice B reason:
A subdural hematoma would not typically cause a decrease in body temperature. This finding may be related to other factors, but it is not a characteristic sign of a subdural hematoma.
Choice C reason:
Correct. A subdural hematoma is a collection of blood between the dura mater and the brain. This can lead to increased intracranial pressure and result in the infant being difficult to arouse.
Choice D reason:
While a weak cry can be an indication of distress or illness in an infant, it is not a specific sign of a subdural hematoma. Other assessments, including neurological signs, are crucial in evaluating the infant's condition.
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