A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Instruct the parent to give 5 mcg of vitamin D daily.

Instruct the parent to give the infant water every 3 hr between feedings.

Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age.

Recommend the parent mix the milk with rice cereal for feedings.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.

B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.

C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.

D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.

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Correct Answer is C

Explanation

Rationale:

A. A small area rug is placed at the front door: Area rugs increase the risk of falls, especially in older adults or clients with mobility issues. Rugs should be removed or secured with non-slip backing to prevent tripping hazards at entrances and high-traffic areas.

B. The water heater is set at 54° C (129.2° F): This temperature is too high and poses a significant risk for burns or scalding. The recommended maximum water heater setting for safety is 49° C (120° F), especially in homes with children or older adults.

C. The batteries in the smoke alarms are changed annually: Changing smoke alarm batteries once a year aligns with fire safety recommendations. Functioning smoke alarms are a critical part of home safety and fire prevention.

D. A single light fixture hangs along the sidewalk to the house: One light may not provide adequate visibility, especially in poor weather or at night. Multiple, evenly spaced light sources are more effective for preventing trips or falls along walkways.

A. Auscultation B. Inspection C. Palpation D. Percussion

Correct Answer is C

Explanation

Rationale:

A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.

B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.

C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.

D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.

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A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

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