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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Providing the client with information about transportation services: This helps address access barriers but focuses on support services rather than directly organizing or integrating healthcare delivery, which is central to coordination of care.
B. Informing the client about providers who accept their health insurance: While helpful, this action centers on financial guidance. It supports access but does not actively bridge or organize care among multiple services or settings.
C. Arranging an appointment for the client with a mobile health clinic: Coordinating an appointment directly connects the client with needed services, especially in underserved rural areas. This reflects active care coordination by ensuring timely access to care and reducing system fragmentation.
D. Encouraging the client to become a self-advocate: Promoting self-advocacy empowers the client in their health journey but does not represent coordination of care. Coordination involves organizing and facilitating access across providers and settings.
Correct Answer is C
Explanation
Rationale:
A. Temperature 36.8° C (98° F): This temperature is within the normal range and does not suggest a current or impending infection. It indicates stable thermoregulation in the postoperative period.
B. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): This WBC count falls within the normal reference range and does not reflect infection or inflammation. No abnormal immune response is indicated by this result.
C. Body mass index of 32: A BMI over 30 is classified as obesity, which increases the risk of poor wound healing and surgical site infections. Excess adipose tissue can impair circulation, oxygenation, and immune response at the wound site.
D. Blood glucose 90 mg/dL (74 to 106 mg/dL): This is a normal fasting glucose level and does not contribute to infection risk. Well-controlled glucose levels are favorable for wound healing and immune function.
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