The parent brings a child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. Which finding will cause the nurse to intervene?
a. Height of 30 inches
b. Weight of 16 pounds
c. Is not yet potty-trained
d. Is not yet walking up stairs
ANS: B
Size increases rapidly during the first year of life. Birth weight doubles in approximately 5 months and triples by 12 months. This infant should weigh at least 18 (6 ? 3) pounds by this calculation. This child needs the nurse to intervene for further assessment. Height increases an average of 1 inch during each of the first 6 months and about 1/2 inch each month until 12 months: 21 + 6 + 3 = 30 (30 inches is the predicted height). Patterns of body function are just now starting to stabilize. It is quite normal for a 12-month-old child to not be potty-trained or walking up stairs yet. These milestones usually occur in the toddler period of development (12 to 36 months).
You might also like to view...
Which answer has terms that come from all three of the following: the problem-solving process, nursing process, and the research process, rather than just one?
a. Assessment, nursing diagnosis, evaluation b. Data collection, methodology, evaluation c. Data collection, problem identification, implementation d. Literature review, design, outcomes
A pedophile tells the nurse, "I feel so guilty and shameful over molesting a child. My family will be so disgusted with me. I could save them from embarrassment if I were gone." What is the nurse's priority action?
a. Set limits on the patient's disclosures. b. Further assess the patient's suicidality. c. Administer a PRN medication for anxiety. d. Explore the patient's feelings of guilt and shame.
Hypovolemic shock is different from neurogenic shock in that it relates to
1. an infectious process. 2. a brain or spinal cord trauma. 3. inadequate cardiac output. 4. volume depletion.
The nurse is assessing the patient with schizophrenia. Which should the nurse recognize as negative symptoms associated with the disorder? (Select all that apply.)
1. The patient is withdrawn. 2. The patient has a blunted affect. 3. The patient reports auditory hallucinations. 4. The patient reports lack of motivation. 5. The patient introduces himself as Pope Francis.