The nurse is assessing a 12-month-old child and needs to determine length. The nurse would correctly use which of the following procedures to obtain this information?
1. Get assistance to measure the child from head to toe in prone position.
2. Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible.
3. Place the child in a supine position and measure from the crown of the head to the heel while holding the legs straight.
4. Have the mother to assist the child in standing in front of a tape measure.
3
Rationale 1: Get assistance to measure the child from head to toe in prone position. The nurse may enlist help from others to measure, but the measurement is from head to heel, not head to toe, and not in prone position.
Rationale 2: Wait until the child is sleeping and hold the child upright in front of a tape measure attempting for the best accuracy possible. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep.
Rationale 3: Place the child in a supine position and measures from the crown of the head to the heel while holding the legs straight. Recumbent length is obtained on persons who cannot stand freely for height measurements. The length is measured using a device, or by having the person lie flat in the supine position and measuring from the crown of the head to the heel with toes pointed upward and knees straight.
Rationale 4: Have the mother to assist the child in standing in front of a tape measure. It is incorrect to hold a client in a standing position to obtain a height measurement, either with the client awake or asleep.
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