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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discouraging daily fruit juice intakE. While excessive fruit juice intake can contribute to weight gain and dental caries, it's not the priority nursing intervention in this scenario.
B. Increasing the number of breastfeedings: Breastfeeding frequency may be appropriate, but without more information about the child's current feeding patterns and growth trajectory, it's not the priority intervention.
C. Discussing the child's feeding patterns: This is the priority intervention because it allows the nurse to assess the child's current feeding habits, including frequency, duration, and type of feedings, to determine if they are appropriate for the child's growth and development.
D. Talking about solid food consumption: Solid food introduction is typically recommended around 6 months of age, but the priority in this scenario is to assess the current feeding
patterns before discussing solid food introduction.
Correct Answer is B
Explanation
A. Epiglottitis
Epiglottitis typically presents with rapid onset of severe sore throat, high fever, difficulty swallowing, and drooling due to inflammation and swelling of the epiglottis. It is a medical emergency requiring immediate intervention but is less likely to present with the described symptoms.
B. Bronchiolitis
Bronchiolitis commonly occurs in infants and young children, often during the winter months. It is characterized by symptoms such as coughing, wheezing, nasal congestion, fever, and
respiratory distress. The described symptoms, including coughing, nasal congestion, and intermittent fever, align with bronchiolitis.
C. Influenza
Influenza typically presents with symptoms such as fever, cough, sore throat, body aches, and fatigue. While coughing and fever are common symptoms of influenza, the presence of apneic spells is less typical of influenza and more indicative of lower respiratory tract infections like bronchiolitis.
D. Croup
Croup is characterized by a barking cough, hoarseness, and respiratory distress often accompanied by stridor. While croup shares some symptoms with bronchiolitis, such as coughing, the absence of stridor in the description suggests bronchiolitis as a more likely diagnosis.
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