The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?

Substituting cow's milk if breast milk is not available

Advising fluid intake per feeding of 5 or 6 ounces

Advocating iron supplements with bottle-feeding

Discouraging the addition of fruit juice to the diet

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

A. The child performs his bedtime preparations autonomously: While autonomy is a key aspect of development, it doesn't directly align with Erikson's stage of industry versus inferiority, which focuses more on the child's sense of competence and mastery of tasks.

B. The child is developing a consciencE. Conscience development is more closely associated with Erikson's previous stage of initiative versus guilt, where children begin to internalize societal standards and expectations.

C. The child signs up for after-school activities: Engaging in after-school activities involves

actively seeking out opportunities for skill development and social interaction, demonstrating the child's initiative and industry.

D. The child becomes aware of the opposite sex: Awareness of gender differences typically

emerges during middle childhood but is not directly related to Erikson's stage of industry versus inferiority, which emphasizes the development of a sense of competence and productivity in

mastering tasks.

A. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016 B. A 10-year-old child who has sickle cell anemia who reports severe chest pain C. A 1-year-old toddler who has roseola and a temperature of 39°C (102.2°F) D. A 4-year-old child who has asthma and a PCO2 of 37 mm

Correct Answer is B

Explanation

A. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016: While diabetes insipidus requires monitoring and management, a urine specific gravity of 1.016 alone does not indicate acute distress or an emergency situation. The child may need adjustments in fluid intake or medication, but this can typically be addressed in a less urgent manner.

B. A 10-year-old child who has sickle cell anemia who reports severe chest pain: Severe chest pain in a child with sickle cell anemia could indicate a vaso-occlusive crisis affecting the chest, which is potentially life-threatening. Prompt assessment and intervention are necessary to

manage the pain and prevent complications, including acute chest syndrome or respiratory compromise.

C. A 1-year-old toddler who has roseola and a temperature of 39°C (102.2°F): Roseola is typically a benign viral illness characterized by fever and a rash. While a fever in a young child

requires monitoring and symptomatic management, it is not usually considered an emergency unless accompanied by other concerning symptoms such as dehydration or respiratory distress.

D. A 4-year-old child who has asthma and a PCO2 of 37 mm: While asthma exacerbations can be serious, a PCO2 level of 37 mm indicates normal carbon dioxide levels, which do not suggest acute respiratory distress or impending respiratory failure. However, if the child is experiencing severe respiratory distress, cyanosis, or altered mental status, immediate assessment and

intervention would be warranted.

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The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is B

Explanation

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