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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Maternal hypertension, or high blood pressure, is not directly associated with precipitous Labor. While hypertension can be a concern during pregnancy, it is not a primary complication resulting from a rapid Labor process. The nurse's focus would be on other specific complications that arise from precipitous Labor.

Choice B reason: Postpartum haemorrhage is a significant risk for patients experiencing precipitous Labor. Rapid Labor can lead to excessive uterine contractions, which might cause trauma to the birth canal, including lacerations and uterine atony (failure of the uterus to contract properly after delivery). These conditions can lead to significant blood loss and necessitate close monitoring and intervention to manage and mitigate the haemorrhage.

Choice C reason: Newborn hyperglycaemia, which refers to elevated blood sugar levels in the newborn, is not related to the process of precipitous Labor. This condition is more commonly associated with maternal diabetes and is not a typical complication the nurse would monitor for in this scenario.

Choice D reason: Premature rupture of membranes, which refers to the breaking of the amniotic sac before Labor begins, is not a complication resulting from precipitous Labor. It is a condition that can precede Labor but is not caused by the rapid progression of Labor. The nurse would be more concerned with managing complications directly related to the rapid Labor and delivery process.

A. Schedule a full neurological evaluation. B. Recommend follow-up in 30 days after documenting the regression. C. Question the parents about changes in the child's activity schedule. D. Document the findings and schedule an 18-month well-visit.

Correct Answer is A

Explanation

Choice A reason: Scheduling a full neurological evaluation is the appropriate action in this scenario. The sudden regression in the child's ability to walk is a significant concern that requires immediate investigation to rule out any underlying neurological or medical conditions. A full neurological evaluation will help identify any issues such as developmental delays, neuromuscular disorders, or other conditions that may be affecting the child's motor skills. Prompt evaluation and diagnosis are crucial for early intervention and appropriate management.

Choice B reason: Recommending follow-up in 30 days after documenting the regression is not an ideal approach in this situation. Given the severity of the regression in the child's walking ability, waiting for 30 days without further investigation could delay critical diagnosis and treatment. Immediate assessment is necessary to address potential underlying issues and provide timely intervention.

Choice C reason: Questioning the parents about changes in the child's activity schedule is important but should not be the sole action taken. While gathering information about the child's activities and environment can provide valuable context, it does not replace the need for a thorough medical evaluation. The primary concern here is the sudden regression in motor skills, which warrants a full neurological assessment.

Choice D reason: Documenting the findings and scheduling an 18-month well-visit is also not sufficient. While it is essential to document the observed regression, delaying further action until the next routine check-up could result in missed opportunities for early diagnosis and intervention. The priority should be to conduct a neurological evaluation to understand the cause of the regression and take appropriate steps to address it.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient experiencing precipitous Labor. What complication will the nurse monitor this patient for?

Correct Answer is B

Explanation

The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?

Correct Answer is A

Explanation

The nurse is assessing a patient in Labor with the findings in the chart: Fatal heart rate 135 with early decelerations. What action will the nurse implement?

The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

The nurse is admitting a 19-year-old patient who has experienced a weight loss of 25 lbs in the past 3 months. Today, the patient weighs 88 lbs and believes they are fat. Which intervention will the nurse prioritize?

The nurse is providing sexually transmitted infection education to a 16-year-old. What nursing intervention demonstrates patient-cantered care?

The nurse is caring for infants with the following conditions. Which infants would be at risk for failure to thrive? Select all that apply.

The nurse is caring for a 12-month-old diagnosed with chronic lung disease, receiving supplemental oxygen with a portable oxygen tank. What developmental milestone is likely to be delayed?

The nurse is teaching the parents of a child with Trisomy 21. Which topic will the nurse include in the teaching plan?

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).