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?

Stops rooting when hungry.

Awakens once for nighttime feedings.

Gives up a bottle for a cup.

Opens mouth when food comes her way.

Answer and Explanation

The Correct Answer is D

A. Stops rooting when hungry. The rooting reflex, which helps newborns find the breast or bottle, typically disappears by 3–4 months of age. However, its absence does not indicate readiness for solid foods. Readiness is more closely linked to developmental milestones such as sitting with support and showing interest in food.
B. Awakens once for nighttime feedings. Nighttime feedings are common in infants up to 6 months and are not a reliable sign of readiness for solid foods. Frequent night waking is often due to normal growth spurts rather than an indication that the baby needs solids.
C. Gives up a bottle for a cup. Transitioning from a bottle to a cup occurs later in infancy, usually around 9–12 months. Introducing solids does not require weaning from the bottle, as infants initially consume solids alongside breast milk or formula.
D. Opens mouth when food comes her way. Readiness for solid foods, typically around 4–6 months, is indicated by signs such as good head control, the ability to sit with support, and showing interest in food by opening the mouth or reaching for it. The American Academy of Pediatrics recommends introducing single-ingredient, iron-fortified foods like rice cereal with a spoon rather than putting it in a bottle, which can increase the risk of choking and overfeeding.

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Correct Answer is D

Explanation

A. Establish the frequency of headaches. While assessing headache history is important, an excruciating headache in a pregnant client with elevated blood pressure is a concerning sign of possible preeclampsia. Immediate evaluation for organ involvement, such as proteinuria, is more critical than determining headache patterns.
B. Ask about a history of delivering large babies. A history of macrosomia is more relevant for assessing gestational diabetes rather than hypertensive disorders. In this case, the priority is identifying potential complications of preeclampsia, which requires urine protein testing.
C. Examine the client for pedal edema. Although edema can be a sign of preeclampsia, it is also common in normal pregnancy. Generalized edema, particularly in the face and hands, may be more concerning, but the presence or absence of edema does not confirm or rule out preeclampsia.
D. Collect a urine sample to screen for protein. Proteinuria is a key diagnostic criterion for preeclampsia, along with hypertension and systemic symptoms such as severe headache. A urine dipstick or 24-hour urine collection helps determine if the client has preeclampsia, which requires urgent management to prevent complications like eclampsia or placental abruption.

A. Arched back. B. Coffee-ground emesis. C. Projectile vomiting. D. Frequent pauses.

Correct Answer is C

Explanation

A. Arched back. An arched back can be seen in conditions such as gastroesophageal reflux disease (GERD) or neurological disorders but is not a hallmark feature of the condition described. The presence of an olive-like mass and hunger despite vomiting suggests a different diagnosis.
B. Coffee-ground emesis. Coffee-ground emesis indicates the presence of digested blood, often seen in gastrointestinal bleeding. This is not a typical finding in infants with the described symptoms, which are more consistent with pyloric stenosis.
C. Projectile vomiting. The combination of dehydration, extreme hunger, and a palpable olive-like mass in the right upper abdomen is classic for hypertrophic pyloric stenosis. This condition causes progressive gastric outlet obstruction, leading to non-bilious, projectile vomiting after feeds. Vomiting occurs because food cannot pass through the thickened pyloric sphincter.
D. Frequent pauses. Frequent pauses during feeding may be observed in conditions such as respiratory distress or neuromuscular disorders, but they are not characteristic of pyloric stenosis. Infants with pyloric stenosis often appear eager to feed but vomit forcefully due to gastric outlet obstruction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer is D

Explanation

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

Correct Answer is C

Explanation

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?

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?

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