The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?

Substituting cow's milk if breast milk is not available

Advising fluid intake per feeding of 5 or 6 ounces

Advocating iron supplements with bottle-feeding

Discouraging the addition of fruit juice to the diet

Answer and Explanation

The Correct Answer is D

A. Substituting cow's milk if breast milk is not availablE. Cow's milk is not recommended as a substitute for breast milk or infant formula for infants under 12 months old due to its low iron content and potential for causing gastrointestinal irritation.

B. Advising fluid intake per feeding of 5 or 6 ounces: The appropriate fluid intake for a 2-week- old infant is typically guided by feeding cues and may vary from feeding to feeding. Providing a specific volume of fluid per feeding may not be appropriate, as infants should be fed on demand.

C. Advocating iron supplements with bottle-feeding: Iron supplementation is generally recommended for breastfed infants starting at around 4 months of age, but it is not typically necessary for formula-fed infants during the first few weeks of life. Additionally, iron

supplementation should be prescribed and monitored by a healthcare provider rather than advocated as a general guideline.

D. Discouraging the addition of fruit juice to the diet: This is the most effective anticipatory guidance because it aligns with current recommendations from pediatric healthcare

organizations. Fruit juice offers little nutritional value for infants and can contribute to dental caries and excessive calorie intake. It is generally recommended to avoid giving fruit juice to infants under 1 year old.

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Correct Answer is B

Explanation

A. Inspection, percussion, palpation, auscultation: This sequence starts with visual inspection, followed by percussion (tapping the body to assess underlying structures), palpation (using the hands to feel for abnormalities), and finally auscultation (listening with a stethoscope to assess sounds such as heart, lung, or bowel sounds). However, palpation is usually performed before percussion.

B. Inspection, palpation, percussion, auscultation: This is the correct sequence for performing a physical examination. It begins with visual inspection, followed by palpation to assess for

tenderness, masses, or other abnormalities, then percussion to evaluate the density of underlying structures, and finally auscultation to listen to internal sounds.

C. Palpation, percussion, inspection, auscultation: This sequence starts with palpation, followed by percussion, then inspection, and finally auscultation. However, inspection is typically performed before palpation in a physical examination.

D. Inspection, auscultation, palpation, percussion: This sequence starts with visual inspection, followed by auscultation, palpation, and percussion. While auscultation often follows inspection, palpation is usually performed before auscultation.

A. Forward-facing in the front passenger seat B. Rear-facing in the back seat next to a window C. Rear-facing in the middle of the back seat D. Forward-facing in the back seat

Correct Answer is C

Explanation

A. Forward-facing in the front passenger seat: This position is not suitable for an infant. Infants should always be placed in a rear-facing car seat in the back seat of the vehicle to reduce the risk of injury in the event of a crash.

B. Rear-facing in the back seat next to a window: Placing an infant next to a window increases the risk for injury. The safest position for a car seat is in the center of the back seat

C. Rear-facing in the middle of the back seat: Although the manufacturer of the car seat will provide specifics regarding use, a child should remain in a rear-facing car seat until age 2 or until the child outgrows the height or weight limits of a rear-facing seat

D. Forward-facing in the back seat: Forward-facing car seats are appropriate for older children, typically after they have outgrown rear-facing car seats based on height and weight requirements.

Infants should always ride in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer.

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The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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