The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, "My mother says I should put rice cereal in the baby's bottle now. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

A. Complete the assessment while allowing the child to cry. Forcing an examination while the child is distressed can heighten anxiety and reduce cooperation. A preschooler needs reassurance and a gradual approach to feel safe before proceeding with the assessment.
B. Explain to the child the reasons an examination is needed. While providing simple explanations is beneficial, preschoolers may not fully understand medical reasoning. Building trust through interaction and distraction is more effective than verbal explanations alone.
C. Talk to the mother and gradually focus on the child's toy. Preschoolers often feel more comfortable when they see their parent engaging positively with the nurse. Redirecting attention to a familiar toy can help ease anxiety, making the child more willing to cooperate with the assessment. This approach builds trust and minimizes fear.
D. Request extra staff to help with the nursing assessments. Bringing in additional staff may make the child feel more overwhelmed and frightened. Gentle, child-friendly engagement techniques should be attempted first before considering restraint or forceful examination.

A. Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B. Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C. Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D. Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E. Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F. Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G. Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.