A mother brings her child to the clinic for a 12-month well ...

[Tirant22]

A mother brings her child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. What finding indicates that the child needs further assessment?
 
  a. Height of 30 inches
  b. Weight of 16 pounds
  c. The infant is not yet potty-trained.
  d. The infant is not yet walking up stairs.

Question 2

The client has a nursing diagnosis of Impaired gas exchange as a result of excess secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus on which of the following client indicators?
 
  a. Ability to perform incentive spirometry
  b. Lungs clearing bilaterally on auscultation
  c. Complaint of chest pain
  d. Respiratory rate

[lcapri7]

Answer to Question 1

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 pounds by this calculation. This child needs 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). In the toddler stage, rapid development of motor skills allows the child to participate in self-care activities such as feeding, dressing, and toileting. Soon the child begins to navigate stairs, using a rail or the wall to maintain balance.

Answer to Question 2

B

Feedback
A The client's ability to perform incentive spirometry does not determine whether the client's airways are clear. It is an intervention that may help achieve clear airways.
B Auscultating lung sounds is the best way to determine whether airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement.
C A complaint of chest pain would be a negative outcome and is not the focus for determining whether airways are free of secretions, as written in the outcome statement.
D Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine whether airways are free of secretions.

[Tirant22]

TYSM

[flexer1n1]

Gracias!