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 C

Explanation

A. Carotid artery: The carotid artery is not typically used to assess heart rate in infants due to its location and difficulty in palpation.

B. Radial artery: The radial artery is not typically used to assess heart rate in infants, especially in non-cooperative or newborn infants.

C. Apex of the heart: Assessing the heart rate by auscultating the apex of the heart with a stethoscope is the most accurate method for infants.

D. Brachial artery: The brachial artery is not typically used to assess heart rate in infants. It is commonly used to measure blood pressure.

A. The newborn does not respond to a loud noise. B. The newborn's eyes focus on near objects. C. The newborn becomes more alert with stroking when drowsy. D. The newborn's eyes wander and occasionally are crossed.

Correct Answer is A

Explanation

A. The newborn does not respond to a loud noise.

A newborn should exhibit a startle response to a loud noise, indicating intact auditory sensory skills. Failure to respond to a loud noise may suggest a deficit in auditory perception.

B. The newborn's eyes focus on near objects.

Focusing on near objects is a normal visual response in newborns as they adjust to their visual environment. This behavior does not necessarily indicate a sensory deficit.

C. The newborn becomes more alert with stroking when drowsy.

Being more alert with stimulation when drowsy is a normal response and does not necessarily indicate a sensory deficit.

D. The newborn's eyes wander and occasionally are crossed.

In newborns, wandering eyes and occasional crossing are common as their visual system continues to develop. This behavior is not necessarily indicative of a sensory deficit at this stage.

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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?

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