A 10-month-old infant is admitted to the hospital with a medical ...

[future617RT]

A 10-month-old infant is admitted to the hospital with a medical diagnosis of dehydration. A nursing assessment reveals decreased vocalization, general lack of interest in the surroundings, and non-engaging behaviors.
 
  Which of these nursing actions takes priority? 1. Allowing the infant to rest quietly and undisturbed in the crib
 
  2. Monitoring the mother's affect
 
  3. Monitoring the infant's response to vocalization when the nurse enters the room
 
  4. Holding and cuddling the infant frequently throughout the day

Question 2

A nurse is assessing an 11-month-old, 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. Nutritional Intake: excessive secondary to maternal feeding patterns
 
  2. Growth Pattern, Altered secondary to familial short stature
 
  3. Growth Pattern, Altered related to parental anxiety
 
  4. Constitutional Growth Delay, risk for related to decreased appetite

[vish98]

Answer to Question 1

2
Rationale:
1. The infant should not be left in the crib undisturbed.
2. The scenario reveals inappropriate infant behaviors. This is a priority question, so all answers might be correct, and you need to select the answer that shows which action should be completed first. The nurse needs to monitor the motherinfant interaction.
3. Monitoring the mother's affect is the priority.
4. The infant should be held and cuddled throughout the day; however, the best answer related to problem identification is observing the mother's affective behavior.

Answer to Question 2

3
Rationale:

1. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake.
2. There are no data that indicate familial short stature.
3. The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is Growth Patterns, Altered related to parental anxiety.
4. This infant is not at risk for constitutional growth delay.

[future617RT]

TYSM

Gracias!