The nurse is assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

Holding head upright and sitting unsupported.

Pushing food out with their tongue.

Grasping small objects and not letting go.

The infant is between 4 and 6 months old.

Answer and Explanation

The Correct Answer is B

Choice A reason: Holding their head upright and sitting unsupported are signs that an infant may be ready for solid foods. These motor skills indicate that the baby has enough control to handle swallowing food safely.

Choice B reason: Pushing food out with their tongue is known as the tongue-thrust reflex, and it is a sign that the infant may not be ready for solid foods yet. This reflex prevents choking and generally diminishes between 4 and 6 months of age.

Choice C reason: Grasping small objects and not letting go demonstrates that the baby has developed fine motor skills, which are also important for starting solid foods. However, this alone does not determine readiness.

Choice D reason: Being between 4 and 6 months old is an appropriate age range for introducing solid foods, as long as other readiness signs are also present. Age alone is not the sole indicator of readiness for solid foods.

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Correct Answer is A

Explanation

Choice A reason: This statement indicates the parent's understanding that vacuum-assisted deliveries can sometimes lead to an increased risk of jaundice. The use of a vacuum can cause bruising on the baby's scalp, which can lead to the breakdown of red blood cells, thereby increasing bilirubin levels. Elevated bilirubin levels can cause jaundice in newborns. Recognizing this potential risk and monitoring the baby for signs of jaundice is an essential aspect of post-delivery care.

Choice B reason: Stating that the procedure was required because the baby was breech is incorrect. Vacuum-assisted delivery is typically used in cases where the baby is in a cephalic (head-first) position and there are difficulties in progressing through the birth canal, such as when the mother is exhausted, or the baby needs to be delivered quickly due to fatal distress. Breech presentations often necessitate a caesarean section instead of a vacuum-assisted delivery.

Choice C reason: The assertion that the vacuum was required because the mother did not dilate past 6 centimetres is inaccurate. Vacuum-assisted delivery is not related to cervical dilation but rather to difficulties encountered during the second stage of Labor (pushing phase). The decision to use a vacuum is made when the baby is in the birth canal, and additional assistance is needed to facilitate delivery.

Choice D reason: Stating that the baby’s head will be cone-shaped for about 2 months is also incorrect. While a vacuum-assisted delivery can result in a temporary cone-shaped head (known as "caput succedaneum" or melding), this typically resolves within a few days to weeks after birth. It is not expected to last for two months. Proper education should clarify the temporary nature of the head shape changes.

A. Human Papillomavirus B. Pneumococcal C. Measles D. Rubella

Correct Answer is A

Explanation

Choice A reason: The Human Papillomavirus (HPV) vaccine is typically recommended for preteens at age 11 or 12 to protect against HPV infections that can lead to certain types of cancer later in life. This vaccine is given as a series of shots, and starting the series at 11 years old is ideal for maximizing its effectiveness before any potential exposure to the virus.

Choice B reason: The Pneumococcal vaccine is generally recommended for infants, young children, and older adults, particularly those with certain health conditions. It protects against pneumococcal disease, including infections in the lungs, blood, and brain. While it is crucial for vulnerable populations, it is not typically administered to healthy 11-year-old children.

Choice C reason: The Measles vaccine is part of the MMR (Measles, Mumps, Rubella) vaccine, which is usually administered in two doses—the first dose at 12-15 months of age and the second dose at 4-6 years of age. By the time a child reaches 11 years old, they would have already received both doses of the MMR vaccine, assuming they followed the standard vaccination schedule.

Choice D reason: The Rubella vaccine is also included in the MMR vaccine, which is given in two doses during early childhood. Since the second dose is typically administered by the age of 6, an 11-year-old child would not require another dose of the Rubella vaccine if they followed the standard vaccination schedule.

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The nurse is assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

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