A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention?

Discouraging daily fruit juice intake

Increasing the number of breastfeedings

Discussing the child's feeding patterns

Talking about solid food consumption

Answer and Explanation

The Correct Answer is C

A. Discouraging daily fruit juice intakE. While excessive fruit juice intake can contribute to weight gain and dental caries, it's not the priority nursing intervention in this scenario.

B. Increasing the number of breastfeedings: Breastfeeding frequency may be appropriate, but without more information about the child's current feeding patterns and growth trajectory, it's not the priority intervention.

C. Discussing the child's feeding patterns: This is the priority intervention because it allows the nurse to assess the child's current feeding habits, including frequency, duration, and type of feedings, to determine if they are appropriate for the child's growth and development.

D. Talking about solid food consumption: Solid food introduction is typically recommended around 6 months of age, but the priority in this scenario is to assess the current feeding

patterns before discussing solid food introduction.

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Correct Answer is A

Explanation

A. The toddler's anterior fontanel is not fully closeD. The closure of the anterior fontanel typically occurs by around 18 months of age. If the fontanel is still open at 3 years old, it may indicate a delay in normal development and could be a cause for concern. The nurse should further assess this finding and consider follow-up with the healthcare provider.

B. The toddler gained 3 in in height since last year: Growth in height is expected during early childhood, and a gain of 3 inches over a year is within the normal range for a 3-year-old.

C. The toddler gained 4 lb in weight since last year: Weight gain is also expected during early childhood, and a gain of 4 pounds over a year is within the normal range for a 3-year-old.

D. The circumference of the child's head increased 1 in since last year: Head circumference typically increases during early childhood as the brain grows, and a 1-inch increase over a year is within the normal range for a 3-year-old.

A. "I will give him a pacifier during feeding time." B. "We need to make sure he doesn't lose the desire to eat by mouth." C. "We need to keep feeding time very quiet." D. "Sucking produces saliva, which aids in digestion."

Correct Answer is A

Explanation

A. "I will give him a pacifier during feeding time.": Giving a pacifier during feeding time may interfere with the infant's ability to coordinate sucking, swallowing, and breathing, especially if

they are receiving nutrition through a nasogastric tube. This response indicates a need for further teaching because pacifiers during feeding time could potentially disrupt the infant's feeding

pattern and may not be appropriate in this situation.

B. "We need to make sure he doesn't lose the desire to eat by mouth.": This response

demonstrates an understanding of the importance of maintaining the infant's oral feeding skills and indicates appropriate knowledge about promoting oral feeding while using a nasogastric

tube.

C. "We need to keep feeding time very quiet.": Keeping feeding time quiet can help reduce distractions and promote a calm environment, which may enhance feeding tolerance for the infant. This response reflects an understanding of strategies to facilitate feeding.

D. "Sucking produces saliva, which aids in digestion.": This response demonstrates knowledge about the benefits of sucking and saliva production during feeding, indicating an understanding of the infant's physiological needs during feeding.

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A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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