Exhibits

The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history.

What should the nurse advise the parents concerning the child's nutrition? Select all that apply

Juice should be avoided in infancy and early childhood

The majority of the child's calories should be coming from the formula

The parents can add raw fruit, cheese, or firmly cooked vegetables to the die

The child should probably be eating more times per day

The parents should consider using a fluoride supplement

The child can now convert to animal milk instead of formula

Answer and Explanation

Correct Answer : A,C,D

A)   Correct- This is correct advice. Juice is not recommended for infants due to its high sugar content and lack of essential nutrients. It can contribute to excessive calorie intake and dental caries.
B)   Incorrect- This is not accurate for a 9-month-old infant. By 9 months, most infants have already started to transition to solid foods, and their primary source of nutrition should be from a variety of solid foods, not formula.
C)   Correct- This is correct advice. By 9 months, infants can begin to consume a variety of complementary foods to meet their nutritional needs. Adding raw fruit, cheese, or cooked vegetables can provide important nutrients and help introduce different tastes and textures.
D)   Correct- As infants transition to solid foods, they typically require more frequent meals and snacks to meet their energy and nutrient needs. Breast milk or formula intake may also gradually decrease as solid foods are introduced.
E)   Incorrect- Fluoride supplementation may be considered based on the fluoride content of the water supply and the child's risk of dental caries. However, this advice is not specific to the child's nutrition and feeding progression.
F. Incorrect- At 9 months, infants should not transition to whole cow's milk as their main source of nutrition. Breast milk or infant formula remains the primary source of nutrition, and cow's milk can be introduced as a beverage and ingredient in cooking after the first year of life.

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Correct Answer is D

Explanation

A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.

A. Collect a blood sample for hemoglobin Alc. B. Give the client a glass of orange juice. C. Notify the healthcare provider. D. Assess client for polyuria and polyphagia.

Correct Answer is B

Explanation

In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:

Give the client a glass of orange juice.

A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.

Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.

Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.

Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.

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Exhibits The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history. What should the nurse advise the parents concerning the child's nutrition? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Correct Answer is B

Explanation

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Exhibits

The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history.

What should the nurse advise the parents concerning the child's nutrition? Select all that apply