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. Give blow-by oxygen via cannula. Blow-by oxygen is used for neonates who are breathing spontaneously but need supplemental oxygen. Since this newborn remains apneic despite stimulation, oxygen alone will not be sufficient to establish effective respiration.
B. Start IV infusion in a scalp vein. IV access may be needed later for medications or fluids, but the immediate priority is establishing effective breathing. Without adequate ventilation, oxygen delivery to tissues will be compromised, making IV interventions secondary.
C. Assist neonatologist with intubation. Intubation is reserved for neonates who fail to respond to positive pressure ventilation (PPV) or who require prolonged respiratory support. Since this newborn has a heart rate of 100 bpm and is apneic, PPV should be initiated first to stimulate breathing before considering intubation.
D. Provide positive pressure ventilation. PPV is the priority intervention for a newborn who remains apneic despite initial stimulation. A heart rate of 100 bpm is reassuring, but without spontaneous breathing, PPV is necessary to ensure adequate oxygenation and prevent further deterioration. Neonatal resuscitation guidelines recommend starting PPV within the first minute of life if the infant does not establish effective respirations.

A. "Tell me what an operation is." B. "We're going to do everything we can to take very good care of you." C. "I'm glad your mother told you why you were coming to the hospital." D. "Are you scared?"

Correct Answer is A

Explanation

A. "Tell me what an operation is." This open-ended question allows the nurse to assess the child’s understanding of the procedure and address any misconceptions or fears. School-age children are in the concrete operational stage of cognitive development, meaning they benefit from clear, age-appropriate explanations. Encouraging them to express their thoughts helps the nurse provide reassurance and correct any misunderstandings.
B. "We're going to do everything we can to take very good care of you." While this statement is comforting, it does not encourage the child to share their knowledge or feelings about the surgery. Understanding the child’s perspective first allows for more effective education and emotional support.
C. "I'm glad your mother told you why you were coming to the hospital." While acknowledging parental involvement is positive, this response does not directly engage the child in conversation or assess their level of understanding. The nurse should focus on what the child knows and feels about the procedure.
D. "Are you scared?" Directly asking if the child is scared may lead to a yes-or-no answer and might introduce fear where it did not previously exist. Instead, allowing the child to explain their understanding of the operation provides insight into their concerns and gives the nurse an opportunity to offer appropriate reassurance.

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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

Correct Answer is D

Explanation

During the admission procedure of a school age child, the child states, "I'm going to have an operation." Which response is best for the nurse to provide to this child?

Correct Answer is A

Explanation

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