The nurse is assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

Holding head upright and sitting unsupported.

Pushing food out with their tongue.

Grasping small objects and not letting go.

The infant is between 4 and 6 months old.

Answer and Explanation

The Correct Answer is B

Choice A reason: Holding their head upright and sitting unsupported are signs that an infant may be ready for solid foods. These motor skills indicate that the baby has enough control to handle swallowing food safely.

Choice B reason: Pushing food out with their tongue is known as the tongue-thrust reflex, and it is a sign that the infant may not be ready for solid foods yet. This reflex prevents choking and generally diminishes between 4 and 6 months of age.

Choice C reason: Grasping small objects and not letting go demonstrates that the baby has developed fine motor skills, which are also important for starting solid foods. However, this alone does not determine readiness.

Choice D reason: Being between 4 and 6 months old is an appropriate age range for introducing solid foods, as long as other readiness signs are also present. Age alone is not the sole indicator of readiness for solid foods.

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Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to ambulate intermittently and change positions can help alleviate early decelerations by improving uteroplacental blood flow and promoting fatal oxygenation. Movement and position changes can reduce compression on the umbilical cord and facilitate Labor progression.

Choice B reason: Placing the patient in the left lateral position can improve uteroplacental blood flow, but increasing the oxytocin rate is not indicated based on the current findings. Early decelerations are typically not a sign of Labor dystocia requiring oxytocin augmentation.

Choice C reason: Administering oxygen via a non-rebreather mask is generally reserved for situations where there is significant fatal distress or non-reassuring fatal heart rate patterns. Early decelerations are usually benign and do not necessitate supplemental oxygen.

Choice D reason: Teaching the patient to push when she feels the urge during contractions is appropriate during the second stage of Labor. However, the current findings with early decelerations do not indicate the need for this intervention at this time. The focus should be on monitoring and managing the fatal heart rate.

A. A 5-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hours ago. B. A 3-year-old toddler who swallowed several sunflower seeds and continues to cough with an oxygen saturation of 91%. C. A 15-year-old adolescent who had a laparoscopic appendectomy 10 hours ago, rates their pain a 3/10, and is preparing for discharge this morning. D. An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hours and ate 70% of their meals.

Correct Answer is B

Explanation

Choice A reason: While a child with asthma exacerbation needs monitoring, they used their rescue inhaler 16 hours ago and are currently stable. This patient is not the highest priority.

Choice B reason: A 3-year-old who continues to cough with an oxygen saturation of 91% is at risk of respiratory distress or obstruction due to the swallowed sunflower seeds. The low oxygen saturation indicates impaired gas exchange and requires immediate attention.

Choice C reason: A 15-year-old recovering from a laparoscopic appendectomy who is stable and preparing for discharge can wait to be seen after more urgent cases.

Choice D reason: An 18-month-old admitted for dehydration who is producing a normal number of wet diapers and eating well indicates improved hydration status and can be seen after addressing the more critical situation.

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The nurse is assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

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