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 D

Explanation

A. Increased intracranial pressurE. Pulsation and bulging of the fontanel may be signs of

increased intracranial pressure in infants. However, it is important to differentiate between normal fontanel characteristics and abnormal signs of elevated intracranial pressure. In this case, the pulsation and bulging are likely normal responses to crying and changes in intracranial pressure during the newborn period.

B. Dehydration: Dehydration typically presents with sunken fontanels rather than pulsation and bulging. Dehydration is a serious condition that requires prompt assessment and intervention, but it is not indicated by the findings described in the scenario.

C. Overhydration: Overhydration is not typically associated with pulsation and bulging of the fontanel. Overhydration may lead to fluid overload and edema but does not directly affect fontanel characteristics.

D. These are normal findings: Pulsation and brief bulging of the fontanel in response to crying are considered normal findings in newborns. Fontanels allow for the flexibility of the skull bones during childbirth and provide space for brain growth during infancy. Pulsation and bulging may occur temporarily during crying or changes in intracranial pressure and are not necessarily

indicative of pathology.

A. "You should leave the room while the tantrum is happening." B. "Temper tantrums are the toddler's attempt to gain control of a situation." C. "Temper tantrums are a type of learning disability." D. "You should get a psychological consult for the temper tantrums."

Correct Answer is B

Explanation

A. "You should leave the room while the tantrum is happening.": Leaving the room during a

toddler's tantrum may not be the most effective strategy, as it may reinforce the behavior or make the child feel abandoned. It is generally recommended to stay nearby and provide support and guidance during tantrums.

B. "Temper tantrums are the toddler's attempt to gain control of a situation.": Temper tantrums are often a normal part of toddler development and can occur when toddlers feel frustrated, overwhelmed, or unable to express their needs effectively. Understanding that tantrums are a way for toddlers to assert some control over their environment can help parents respond appropriately.

C. "Temper tantrums are a type of learning disability.": Temper tantrums are not indicative of a learning disability. While they can be challenging for parents to manage, they are typically considered a normal phase of development and are not associated with cognitive impairments.

D. "You should get a psychological consult for the temper tantrums.": Seeking psychological consultation for temper tantrums may be unnecessary unless there are other concerning behaviors or developmental delays present. Tantrums are typically addressed through behavior

management techniques and parent education rather than psychological intervention.

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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 assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?

Correct Answer is D

Explanation

A nurse is teaching the parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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