In providing anticipatory guidance to the mother of a two-month old breast-fed infant, which of the following should the nurse include:
You will need to start supplementing your baby with iron drops immediately because breastmilk does not contain any iron.
Your baby's iron levels will remain normal as long as you continue breast-feeding.
Your baby will need iron supplementation in the next few months because her iron stores from you will be depleted.
You need to start solids now to give your baby some iron rich foods.
The Correct Answer is C
Choice A reason: This is incorrect because breastmilk does contain some iron, although not as much as formula. However, the iron in breastmilk is more bioavailable and easily absorbed by the infant. Therefore, iron drops are not necessary for exclusively breast-fed infants until they are 4 to 6 months old.
Choice B reason: This is incorrect because the iron levels of breast-fed infants will start to decline after 4 to 6 months of age, as their iron stores from the mother are used up. Therefore, they will need iron supplementation from other sources, such as iron-fortified cereals or drops.
Choice C reason: This is correct because the iron stores of breast-fed infants are sufficient for the first 4 to 6 months of life, but then they will need additional iron from other sources. Iron supplementation can prevent or treat iron deficiency anemia, which can affect the infant's growth and development.
Choice D reason: This is incorrect because solids are not recommended for infants younger than 4 months of age, as their digestive system is not mature enough to handle them. Solids can also interfere with the intake of breastmilk, which is the main source of nutrition for infants. Iron-rich foods can be introduced after 6 months of age, along with continued breast-feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as standard precautions are the minimum level of infection control practices that should be applied to all patients, regardless of their diagnosis or presumed infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe handling of sharps and contaminated items, and environmental cleaning. Standard precautions are sufficient for most patients with HIV, unless they have other infections that require additional precautions.
Choice B reason: This statement is incorrect, as droplet precautions are not required for patients with HIV, unless they have other infections that are transmitted by respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorting with other patients with the same infection, and limiting the movement of the patient outside the room.
Choice C reason: This statement is incorrect, as contact precautions are not required for patients with HIV, unless they have other infections that are transmitted by direct or indirect contact, such as Clostridioides difficile, scabies, or herpes simplex virus. Contact precautions include wearing gloves and gowns when entering the patient's room, placing the patient in a private room or cohorting with other patients with the same infection, and dedicating patient-care equipment to the patient or disinfecting it before use on another patient.
Choice D reason: This statement is incorrect, as airborne precautions are not required for patients with HIV, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the symptoms described by the mother are not typical of a formula allergy. A formula allergy would cause symptoms such as rash, hives, wheezing, or vomiting within minutes or hours of feeding. Switching to a soy based formula is not recommended without consulting a doctor, as some infants may also be allergic to soy.
Choice B reason: This is incorrect because feeding the infant after vomiting and diarrhea may worsen the condition and cause more dehydration. The infant should be given small amounts of oral rehydration solution (ORS) or breastmilk to prevent fluid loss. If the infant cannot tolerate oral fluids or shows signs of severe dehydration, such as sunken eyes, dry mouth, or lethargy, they should be taken to the emergency department for intravenous rehydration.
Choice C reason: This is incorrect because blood and mucous in the stool are not normal findings in infants and should be investigated promptly. They may indicate a serious condition such as intussusception, which is a telescoping of the bowel that causes obstruction and inflammation. The stool may look like currant jelly due to the presence of blood and mucous. Intussusception is a medical emergency that requires immediate treatment.
Choice D reason: This is correct because the infant's symptoms may indicate a serious condition such as intussusception, which can be life-threatening if left untreated. The infant should be taken to the emergency room for further evaluation and management. The nurse should also advise the mother to monitor the infant's vital signs, hydration status, and urine output until they reach the hospital.
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