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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pulse rate is increased.
While there may be variations in pulse rate due to factors such as activity level and emotional state, a significant increase in pulse rate would not be a typical finding during an annual check- up for an 8-year-old child.
B. Breathing is diaphragmatic.
As children grow older, their respiratory patterns mature, and they develop diaphragmatic breathing, which is deeper and more efficient than the shallow breathing observed in infants. This change would be expected as the child gets older.
C. Secondary sex characteristics are present.
The development of secondary sex characteristics typically occurs during puberty, which begins around the ages of 9 to 13 in girls and 10 to 14 in boys. At 8 years old, it would be unlikely for significant secondary sex characteristics to be present.
D. Blood pressure has reached adult level.
Blood pressure in children gradually increases with age, but it does not reach adult levels until adolescence. At 8 years old, the child's blood pressure would still be within the pediatric range and would not resemble adult levels.
Correct Answer is C
Explanation
A. The child exhibits plantar grasp reflex: The presence of the plantar grasp reflex at 10 months
is appropriate and not cause for concern. This reflex typically diminishes by around 9 months but can persist slightly longer in premature infants.
B. The child has doubled his birth weight: Doubling birth weight by around 6 months is a normal developmental milestone, and achieving this by 10 months is appropriate, indicating healthy growth.
C. No primary teeth have erupted yet: The absence of primary teeth by 10 months, especially in a preterm infant, may indicate a delay in dental development and should prompt further evaluation by a healthcare provider.
D. The child's head circumference is 49.53 cm: The head circumference of 49.53 cm falls within the typical range for a 10-month-old infant and is not inherently concerning.
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