A nurse is assessing an 11-month-old infant and notes that the ...

[audie]

A nurse is assessing an 11-month-old infant and notes that the infant's height and weight are at the 5th percentile on the growth chart.
 
  Family history reveals that the infant's two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority?
  1. Alteration in Growth Pattern Related to Parental Anxiety
  2. Alteration in Growth Pattern Secondary to Familial Short Stature
  3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns
  4. At Risk for Constitutional Growth Delay Related to Decreased Appetite

Question 2

A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit.
 
  Which statement by the nurse is most appropriate in this situation?
  1. My, you are dressing your infant warmly today.
  2. Did you think it was cold when you left your home this morning?
  3. I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise.
  4. When you leave the office, only put one layer of clothing on your baby.

[IAPPLET]

Answer to Question 1

Correct Answer: 1
Rationale: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Answer to Question 2

Correct Answer: 3
Rationale: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

[audie]

Excellent

[JaynaD87]

TYSM