A mother who intended to breastfeed has given birth to an infant with a cleft palate. Which nursing interventions should be included in the plan of care?
Encouraging and helping mother to breastfeed
Teaching mother to feed breast milk by gavage
Giving medication to suppress lactation
Providing mother with the appropriate formula for the patient
The Correct Answer is A
Choice A reason: Encouraging and helping mother to breastfeed is a supportive and beneficial nursing intervention for a mother who has given birth to an infant with a cleft palate. Breastfeeding provides optimal nutrition, immunity, and bonding for the infant, and may also help prevent infections and promote healing of the cleft. Breastfeeding may be possible for some infants with cleft palate, especially if the cleft is mild or only affects the soft palate. The nurse should assist the mother with positioning, latching, and using devices such as a nipple shield, a breast pump, or a supplemental nursing system. The nurse should also monitor the infant's weight gain, hydration, and output, and provide emotional support and education to the mother.
Choice B reason: Teaching mother to feed breast milk by gavage is not a necessary or desirable nursing intervention for a mother who has given birth to an infant with a cleft palate. Gavage feeding is a method of providing nutrition through a tube that is inserted through the nose or mouth into the stomach. It is usually used for infants who have severe feeding difficulties or other medical conditions that require tube feeding. However, most infants with cleft palate can be fed orally with proper techniques and equipment, and do not need gavage feeding. Gavage feeding may have complications such as infection, irritation, displacement, or obstruction of the tube. It may also interfere with the infant's oral development and bonding with the mother.
Choice C reason: Giving medication to suppress lactation is not a helpful or respectful nursing intervention for a mother who has given birth to an infant with a cleft palate. Medication to suppress lactation is a drug that inhibits the production of breast milk. It is usually used for mothers who choose not to breastfeed or who have medical contraindications to breastfeeding. However, a cleft palate is not a contraindication to breastfeeding, and the mother may still want to breastfeed or express breast milk for her infant. Giving medication to suppress lactation may cause side effects such as nausea, headache, or depression. It may also deprive the infant of the benefits of breast milk, and the mother of the choice and satisfaction of breastfeeding.
Choice D reason: Providing mother with the appropriate formula for the patient is not a sufficient or comprehensive nursing intervention for a mother who has given birth to an infant with a cleft palate. Formula is an artificial substitute for breast milk that provides nutrition for infants who cannot or do not breastfeed. Formula may be used for infants with cleft palate, especially if breastfeeding is not possible or adequate. However, formula does not provide the same immunity, protection, and bonding as breast milk. Providing formula alone does not address the mother's needs, preferences, or feelings about feeding her infant. The nurse should also offer other options, such as expressing breast milk, using a special bottle or cup, or combining breastfeeding and formula feeding. The nurse should also teach the mother how to prepare, store, and administer the formula safely and hygienically.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Mild abdominal pain is not an urgent finding in a child who had emergency reduction for intussusception. It is expected that the child may have some discomfort after the procedure, which can be managed with analgesics and comfort measures. Mild abdominal pain does not indicate a recurrence or complication of intussusception.
Choice B reason: Currant jelly stools are a serious finding in a child who had emergency reduction for intussusception. They are a sign of bowel ischemia and necrosis, which can lead to perforation and peritonitis. Currant jelly stools are stools mixed with blood and mucus, which have a red or purple color and a jelly-like consistency. They are caused by the pressure of the intussuscepted bowel segment on the blood vessels, resulting in bleeding and inflammation. Currant jelly stools indicate that the intussusception has not been completely reduced or has recurred, and require immediate medical attention.
Choice C reason: Axillary temperature of 37.3°C is not an alarming finding in a child who had emergency reduction for intussusception. It is within the normal range for an axillary temperature, which is usually lower than the oral or rectal temperature. A slight elevation of temperature may also be due to the stress of the procedure or a mild infection, which can be treated with antibiotics and fluids. Axillary temperature of 37.3°C does not suggest a serious complication of intussusception.
Choice D reason: BP of 100/54 is not a worrisome finding in a child who had emergency reduction for intussusception. It is within the normal range for a 10-month-old child, which is about 90/60 mmHg. A slight variation of blood pressure may also be influenced by factors such as activity, emotion, pain, or medication. BP of 100/54 does not indicate a problem with the child's circulation or cardiac function.
Correct Answer is A
Explanation
Choice A reason: Abdominal pain that is most intense at McBurney point is a classic sign of acute appendicitis. McBurney point is located about two-thirds of the way from the navel to the right hip bone. It is the site of the base of the appendix, where the inflammation is most severe. The pain usually starts around the navel and then shifts to the lower right abdomen. The pain may worsen with movement, coughing, or pressure.
Choice B reason: Rebound tenderness is a symptom of peritonitis, which is a complication of acute appendicitis. Peritonitis is an inflammation of the lining of the abdominal cavity, which can occur if the appendix ruptures and spills its contents. Rebound tenderness is a sharp pain that occurs when the abdomen is quickly released after being gently pressed. It indicates irritation of the peritoneum, the membrane that covers the abdominal organs.
Choice C reason: Abdominal pain that is relieved by eating is not a typical feature of acute appendicitis. In fact, appendicitis may cause loss of appetite, nausea, and vomiting. Eating may worsen the pain by stimulating the digestive tract and increasing the pressure on the appendix.
Choice D reason: Bright red or dark red rectal bleeding is not a common manifestation of acute appendicitis. It may indicate other conditions, such as hemorrhoids, anal fissures, diverticulitis, ulcerative colitis, or colon cancer. Rectal bleeding may occur in some cases of appendicitis if the inflammation affects the cecum, the first part of the colon, but it is usually not bright or dark red.
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