The nurse admits a 6-month-old to the pediatrician's office for a well-baby exam and immunizations. The nurse undresses the baby and places him on the scale, and he begins to cry
After obtaining measurements, the nurse dresses the baby and hands him to the mother for comforting. What action will the nurse take next? 1. Obtain vital signs.
2. Examine the tympanic membrane.
3. Obtain a history of developmental milestones from the mother.
4. Auscultate heart and lung sounds.
3
Rationale: The order of performing an examination on the infant must be carefully coordinated to collect information while the baby is quiet, so the nurse will talk with the mother while the mother calms the infant. Vital signs and examination of the tympanic membrane while or after the baby has been crying will yield inaccurate results, and it is hard to hear heart sounds in a fussy baby.
You might also like to view...
Procainamide was prescribed for a patient who has ventricular tachycardia. The nurse explains to the patient some adverse actions of this medication. (Select all that apply.)
1. Anorexia 2. Hypotension 3. Flushness in the face 4. Cool hands
Which information should the nurse include in the teaching plan for a patient receiving clozapine (Clozaril)?
a. "Abstain from using tobacco products." b. "Increase your daily carbohydrate intake." c. "Notify your health care provider if you start drooling." d. "You will need monthly electrocardiographic tracings done."
A client has returned to the unit following a wedge resection of the left lung for the presence of a tumor. Which of the following would the nurse have as a priority goal for this client?
1. Maintain current weight 2. Express feelings and concerns 3. Maintain a patent airway 4. Participation in care by the client
Immune system changes that render older adults more susceptible to contracting HIV include all of the following except
A. Hyper-responsive T cells B. Age-related thymic involution C. Depletion of naïve CD4 cells D. Decline in B cell function