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 B

Explanation

A. Vary the child's schedule each day: While some variation in activities may be beneficial, providing a stable and predictable routine can also promote a sense of security and stability for the child during hospitalization.

B. According to Erikson's psychosocial development theory, the psychosocial stage for a 10- year-old child is industry versus inferiority. During this stage, children are developing a sense of competence by mastering new skills and tasks. Encouraging the child to complete school work supports this developmental stage by fostering a sense of accomplishment and competence. It

also helps maintain a sense of normalcy and continuity with academic activities despite the hospitalization.

C. Discourage visits from the client's friends: Social interaction with peers is important for the child's emotional well-being and development. Discouraging visits from friends would likely have a negative impact on the child's psychosocial needs during hospitalization.

D. Provide a daily session with a play therapist: While play therapy may be beneficial for addressing emotional needs, it may not directly address the child's psychosocial development according to Erikson's theory. Encouraging completion of school work aligns more closely with the developmental tasks of this stage.

A. Body weight B. Skin integrity C. Respiratory rate D. Blood pressure

Correct Answer is A

Explanation

A. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.

B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of

dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.

C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.

D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.

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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

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is A

Explanation

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