The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty?

A. Pulse rate is increased.

While there may be variations in pulse rate due to factors such as activity level and emotional state, a significant increase in pulse rate would not be a typical finding during an annual check- up for an 8-year-old child.

B. Breathing is diaphragmatic.

As children grow older, their respiratory patterns mature, and they develop diaphragmatic breathing, which is deeper and more efficient than the shallow breathing observed in infants. This change would be expected as the child gets older.

C. Secondary sex characteristics are present.

The development of secondary sex characteristics typically occurs during puberty, which begins around the ages of 9 to 13 in girls and 10 to 14 in boys. At 8 years old, it would be unlikely for significant secondary sex characteristics to be present.

D. Blood pressure has reached adult level.

Blood pressure in children gradually increases with age, but it does not reach adult levels until adolescence. At 8 years old, the child's blood pressure would still be within the pediatric range and would not resemble adult levels.

A. Substituting cow's milk if breast milk is not availablE. Cow's milk is not recommended as a substitute for breast milk or infant formula for infants under 12 months old due to its low iron content and potential for causing gastrointestinal irritation.

B. Advising fluid intake per feeding of 5 or 6 ounces: The appropriate fluid intake for a 2-week- old infant is typically guided by feeding cues and may vary from feeding to feeding. Providing a specific volume of fluid per feeding may not be appropriate, as infants should be fed on demand.

C. Advocating iron supplements with bottle-feeding: Iron supplementation is generally recommended for breastfed infants starting at around 4 months of age, but it is not typically necessary for formula-fed infants during the first few weeks of life. Additionally, iron

supplementation should be prescribed and monitored by a healthcare provider rather than advocated as a general guideline.

D. Discouraging the addition of fruit juice to the diet: This is the most effective anticipatory guidance because it aligns with current recommendations from pediatric healthcare

organizations. Fruit juice offers little nutritional value for infants and can contribute to dental caries and excessive calorie intake. It is generally recommended to avoid giving fruit juice to infants under 1 year old.