A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention?

Discouraging daily fruit juice intake

Increasing the number of breastfeedings

Discussing the child's feeding patterns

Talking about solid food consumption

Answer and Explanation

The Correct Answer is C

A. Discouraging daily fruit juice intakE. While excessive fruit juice intake can contribute to weight gain and dental caries, it's not the priority nursing intervention in this scenario.

B. Increasing the number of breastfeedings: Breastfeeding frequency may be appropriate, but without more information about the child's current feeding patterns and growth trajectory, it's not the priority intervention.

C. Discussing the child's feeding patterns: This is the priority intervention because it allows the nurse to assess the child's current feeding habits, including frequency, duration, and type of feedings, to determine if they are appropriate for the child's growth and development.

D. Talking about solid food consumption: Solid food introduction is typically recommended around 6 months of age, but the priority in this scenario is to assess the current feeding

patterns before discussing solid food introduction.

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Correct Answer is B

Explanation

A. At 6 years, children are expected to have mastered the ability to descend stairs without needing to place both feet on each step or hold onto the railing.

B. By 3 years of age, children typically begin to walk up stairs using a reciprocal pattern, placing only one foot on each step, but may still require a railing for support when going down.

C. At 4 years, children should be able to go both up and down stairs using a reciprocal pattern and without the need for a rail.

D. By 5 years, the expectation is that children can confidently navigate stairs in a manner similar to adults, without placing both feet on each step or requiring railing support.

A. At the beginning B. Before auscultating the chest and abdomen C. Before examining the head and neck D. At the end

Correct Answer is D

Explanation

A. At the beginning: It is not necessary to examine the tympanic membrane at the very beginning of the physical examination.

B. Before auscultating the chest and abdomen: While the tympanic membrane examination may precede auscultation of the chest and abdomen, it is not typically performed before all other components of the physical examination.

C. Before examining the head and neck: Examination of the tympanic membrane is usually part of the head and neck assessment, so it would not occur before examining these areas.

D. At the enD. Examination of the tympanic membrane is typically performed towards the end of the physical examination, after other components such as inspection, palpation, and auscultation have been completed. This sequence allows the nurse to maintain the flow of the examination and ensures a thorough assessment of all body systems.

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A 6-month-old girl weighs 14.7 lb during a scheduled check-up. Her birth weight was 8 lb. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions aredevelopmentally appropriate at which of the following ages?

Correct Answer is B

Explanation

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

Correct Answer is D

Explanation

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