A nurse plans a physical examination of an infant who is sleeping. What action should the nurse plan to perform first?
Check the infant for diaper rash
Measure the infant's length
Auscultate the infant's breath sounds
Assess the infant's muscle tone
The Correct Answer is C
Choice A reason: Checking for a diaper rash requires undressing the infant and manipulating their limbs, which is highly likely to wake them. In pediatric assessment, intrusive or potentially uncomfortable procedures should always be delayed until the end of the examination to maintain the infant's cooperation and physiological baseline.
Choice B reason: Measuring length involves stretching the infant out on a measuring board, which is a stimulating and often upsetting procedure for a baby. Performing this first would cause the infant to cry, making it impossible to accurately assess heart and lung sounds due to the resulting respiratory and vocal noise.
Choice C reason: The nurse should always perform the least invasive and quietest assessments first while an infant is sleeping. Auscultating the heart, lungs, and abdomen while the child is still allows the nurse to hear clear sounds without the interference of crying, movement, or increased heart and respiratory rates.
Choice D reason: Assessing muscle tone involves manipulating the infant's extremities to check for resistance and recoil. This physical contact is stimulating and will likely disturb the infant's sleep. Like measuring and diaper checks, this should be deferred until the nurse has completed the "quiet" portions of the physical assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Workplace ventilation systems are considered engineering controls that reduce the concentration of airborne contaminants in the general environment. While essential for overall safety, they do not provide localized, high-level filtration for an individual worker who may be in direct contact with concentrated harmful particulates or toxic fumes.
Choice B reason: A portable personal air monitor is a diagnostic tool used to measure the levels of exposure to specific substances. While it provides critical data for safety audits, it is a passive device that does not provide a physical barrier or active protection against inhaling the substances it is monitoring.
Choice C reason: Standard surgical masks are designed primarily to protect the environment from the wearer's respiratory droplets and provide limited protection against large splashes. They do not have a tight facial seal and cannot filter out small, hazardous airborne particles or aerosols found in high-risk occupational settings.
Choice D reason: A fitted N95 respirator is a piece of personal protective equipment (PPE) specifically designed to achieve a very close facial fit and very efficient filtration of airborne particles. By filtering at least 95% of airborne particles, it provides the most effective individualized biological and particulate barrier for the lungs.
Correct Answer is A
Explanation
Choice A reason: Non-modifiable risk factors are those that an individual cannot change, such as age, gender, race, and genetic predisposition. Family history is a primary non-modifiable risk factor; inquiring about it shows the client recognizes that their inherited biological background contributes significantly to their overall cardiovascular risk profile.
Choice B reason: Making an appointment with a dietician is an action aimed at changing modifiable risk factors. Diet, weight, and nutritional intake are behaviors that can be controlled or altered through intervention. While beneficial for heart health, they do not fall under the category of non-modifiable biological traits.
Choice C reason: Limiting alcohol intake is a lifestyle modification. Alcohol consumption is a behavioral choice that can impact blood pressure and lipid levels. Because the client has the power to change this behavior, it is categorized as a modifiable risk factor rather than an inherent, unchangeable biological factor.
Choice D reason: Starting a regular walking schedule addresses physical inactivity, which is a modifiable risk factor. Increasing physical exertion improves cardiovascular health and can be initiated at the client's discretion. This does not reflect an understanding of factors like age or genetics that are beyond personal control
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