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 ["A","C","E"]
Explanation
Rationale:
A. Keep objects in the client's room in the same place: Maintaining a consistent environment helps clients with vision loss navigate safely and confidently. Sudden changes in object placement can increase the risk of disorientation and injury.
B. Ensure there is high-wattage lighting in the client's room: While good lighting benefits clients with partial vision, high-wattage lighting can cause glare or discomfort. The focus should be on well-distributed, non-glare lighting suited to individual needs rather than universally high intensity.
C. Touch the client gently to announce presence: Gently touching a visually impaired client before speaking helps avoid startling them and fosters trust. It is a respectful way to make presence known when visual cues are unavailable.
D. Approach the client from the side: Approaching from the front is preferable so the client can better perceive the nurse's presence through remaining visual fields or auditory cues. Side approaches may lead to disorientation or surprise.
E. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to complete self-care or communication tasks. Rushing them can increase stress and compromise safety, so patience supports their independence.
Correct Answer is D
Explanation
Rationale:
A. “Dehydration is treated with calcium supplements.": Calcium supplementation is not a standard treatment for dehydration. Dehydration is primarily managed with fluid replacement, either orally or intravenously, depending on severity.
B. "Dehydration is caused by a decreased hemoglobin and hematocrit.": Dehydration often causes increased hemoglobin and hematocrit levels due to hemoconcentration, not a decrease. These lab values are used to assess hydration status but do not cause dehydration.
C. "Dehydration is associated with gastroesophageal reflux”: GERD is not a direct cause or result of dehydration. While fluid intake can influence GI symptoms, GERD and dehydration are unrelated conditions with different pathophysiologies.
D. "Dehydration can increase the risk for preterm labor”: Dehydration can trigger the release of antidiuretic hormone and oxytocin, both of which may lead to uterine contractions. It is a recognized risk factor for preterm labor and should be addressed promptly.
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