In providing anticipatory guidance to the mother of a two-month old breast-fed infant, which of the following should the nurse include:
You will need to start supplementing your baby with iron drops immediately because breastmilk does not contain any iron.
Your baby's iron levels will remain normal as long as you continue breast-feeding.
Your baby will need iron supplementation in the next few months because her iron stores from you will be depleted.
You need to start solids now to give your baby some iron rich foods.
The Correct Answer is C
Choice A reason: This is incorrect because breastmilk does contain some iron, although not as much as formula. However, the iron in breastmilk is more bioavailable and easily absorbed by the infant. Therefore, iron drops are not necessary for exclusively breast-fed infants until they are 4 to 6 months old.
Choice B reason: This is incorrect because the iron levels of breast-fed infants will start to decline after 4 to 6 months of age, as their iron stores from the mother are used up. Therefore, they will need iron supplementation from other sources, such as iron-fortified cereals or drops.
Choice C reason: This is correct because the iron stores of breast-fed infants are sufficient for the first 4 to 6 months of life, but then they will need additional iron from other sources. Iron supplementation can prevent or treat iron deficiency anemia, which can affect the infant's growth and development.
Choice D reason: This is incorrect because solids are not recommended for infants younger than 4 months of age, as their digestive system is not mature enough to handle them. Solids can also interfere with the intake of breastmilk, which is the main source of nutrition for infants. Iron-rich foods can be introduced after 6 months of age, along with continued breast-feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as Tanner staging is not based on chronological age, but on the physical development of the child. Children may enter and progress through puberty at different ages, depending on their genetic, environmental, and nutritional factors.
Choice B reason: This statement is incorrect, as Tanner staging is not based on the sexual behavior of the child, but on the appearance of the external genitalia, breasts, and pubic hair. Sexual behavior is influenced by many factors, such as social, cultural, and psychological factors, and does not necessarily correlate with the stage of puberty.
Choice C reason: This statement is incorrect, as Tanner staging is not based on the increase in height and weight, but on the maturation of the reproductive organs and secondary sex characteristics. Height and weight are affected by many factors, such as nutrition, health, and genetics, and do not necessarily reflect the stage of puberty.
Choice D reason: This statement is correct, as Tanner staging is based on the predictable stages of puberty that are based on primary and secondary sexual characteristics. Primary sexual characteristics are the development of the internal and external reproductive organs, such as the ovaries, testes, uterus, penis, and vagina. Secondary sexual characteristics are the changes that occur in other parts of the body, such as the breasts, pubic hair, axillary hair, voice, and body shape.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as suctioning the mouth and nasopharyngeal passages is the most important priority for airway care in an infant who has had a cleft palate repair. The nurse should suction the infant frequently and gently to remove any blood, mucus, or secretions that may obstruct the airway or cause aspiration. The nurse should also monitor the infant's respiratory rate, oxygen saturation, and signs of distress.
Choice B reason: This statement is incorrect, as giving IV morphine for pain is not the most important priority for airway care in an infant who has had a cleft palate repair. Although pain management is essential for the infant's comfort and recovery, it is not the first intervention for airway care. The nurse should assess the infant's pain level and administer the prescribed analgesics as needed, but only after ensuring the airway is clear and patent.
Choice C reason: This statement is incorrect, as cleaning the suture line with normal saline is not the most important priority for airway care in an infant who has had a cleft palate repair. Although wound care is important for the prevention of infection and the promotion of healing, it is not the first intervention for airway care. The nurse should clean the suture line with sterile saline or water as ordered, and avoid using cotton swabs or hydrogen peroxide that may damage the tissue or cause bleeding.
Choice D reason: This statement is incorrect, as elevating the head of the bed 30 degrees is not the most important priority for airway care in an infant who has had a cleft palate repair. Although elevating the head of the bed can help reduce the swelling and improve the drainage, it is not the first intervention for airway care. The nurse should position the infant on the side or abdomen, with the head slightly elevated, and avoid placing the infant on the back or putting pressure on the operative site.
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