A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Instruct the parent to give 5 mcg of vitamin D daily.

Instruct the parent to give the infant water every 3 hr between feedings.

Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age.

Recommend the parent mix the milk with rice cereal for feedings.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.

B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.

C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.

D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices

Endometritis: This uterine infection is common after cesarean delivery, especially with prolonged rupture of membranes. The client’s uterine tenderness, elevated fundus, boggy consistency, and foul-smelling lochia are hallmark signs of endometritis, making it the most likely diagnosis.
Uterus and lochia: The presence of a tender uterus that is elevated above the umbilicus and only firms with massage, combined with dark, malodorous lochia, strongly suggests infection of the uterine lining. These findings point specifically to endometritis rather than general postpartum changes.

Rationale for Incorrect Choices

Mastitis: Although the client reports heavy, warm breasts with nipple discomfort, there is no breast erythema, localized swelling, or high-grade fever typical of mastitis. These symptoms are likely due to engorgement related to lactation rather than infection.
Pneumonia: The client’s respiratory assessment shows clear lungs with only slight basal changes common postoperatively. There are no signs of cough, sputum production, hypoxia, or respiratory distress, which makes pneumonia an unlikely cause of her symptoms.
Fever: A temperature of 38.2°C is above normal, but mild postpartum fever can have various causes, including engorgement, dehydration, or early infection. Fever alone is not specific enough to confirm a diagnosis without targeted findings.
WBC count: Although an elevated WBC of 33,000/mm³ raises concern, postpartum leukocytosis can be physiologic or related to many infections. It is not diagnostic of endometritis without more specific correlating signs like uterine tenderness and abnormal lochia.

A. Hypotension B. Hypovolemia C. Cardiogenic shock D. Left ventricular failure

Correct Answer is D

Explanation

Rationale:

A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.

B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.

C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.

D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.

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A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is most likely experiencing dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

Correct Answer is D

Explanation

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