A client with a nasogastric tube has an order for the tube to be removed.
As the nurse removes the tube, the client should be asked to:

Choice A rationale

Introducing whole milk at 6 months is generally too early. At this age, an infant's primary nutrition should still come from breast milk or formula, which are specifically formulated to meet their developmental needs. The infant's digestive system is still maturing and may not be fully ready to process the higher protein and fat content of whole cow's milk.

Choice B rationale

Transitioning to whole milk at 8 months is also typically premature. While some infants might show readiness signs earlier, the American Academy of Pediatrics recommends waiting until closer to 12 months. Introducing whole milk too soon can displace the intake of breast milk or formula, potentially leading to deficiencies in essential nutrients like iron.

Choice C rationale

Waiting until 10 months is closer to the recommended timeframe, but most guidelines still advise waiting until 12 months. This allows the infant's digestive system more time to mature and ensures they receive optimal nutrition from breast milk or formula for a longer duration. Early introduction of whole milk doesn't offer any significant nutritional advantages over breast milk or formula during this period.

Choice D rationale

The American Academy of Pediatrics recommends transitioning to whole cow's milk around 12 months of age for most infants. By this time, their digestive system is more mature and capable of handling the nutrients in whole milk. Additionally, most infants at this age are consuming a wider variety of solid foods, which helps ensure they are meeting their nutritional needs beyond just milk.

Choice A rationale

Increased hair growth is typically associated with hormonal imbalances, such as an excess of androgens, or certain medications, not generally with undernutrition. Adequate nutrition is essential for maintaining normal hair growth cycles. Nutritional deficiencies often lead to hair thinning or loss, rather than increased growth.

Choice B rationale

A sore, inflamed buccal cavity, also known as stomatitis or mucositis, can be a direct consequence of inadequate nutrition, particularly deficiencies in B vitamins, iron, and vitamin C. These nutrients are crucial for maintaining the health and integrity of the oral mucous membranes. Inflammation and soreness can make eating painful, further contributing to poor nutrient intake.

Choice C rationale

Adequate nutrient or food intake directly contradicts the nursing diagnosis of imbalanced nutrition, less than body requirements. This finding would indicate that the patient's nutritional needs are being met, and the diagnosis would be inaccurate. The presence of dysphagia suggests difficulty in achieving adequate intake.

Choice D rationale

A weight within 10% of ideal body weight suggests that the patient's nutritional status is likely adequate, not less than body requirements. While dysphagia can lead to weight loss, a weight within the normal range indicates that the patient has been able to maintain their weight despite potential swallowing difficulties.