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 D
Explanation
Choice A reason: This is not a correct statement, as somnolence, hypotension, and oliguria are signs of decompensated shock, not compensated shock. These indicate that the child's blood pressure and urine output are dropping, and that the brain is not receiving enough oxygen.
Choice B reason: This is not a correct statement, as hypotension is a sign of decompensated shock, not compensated shock. This indicates that the child's blood pressure is falling below normal levels, and that the compensatory mechanisms are failing.
Choice C reason: This is not a correct statement, as bradycardia is a sign of irreversible shock, not compensated shock. This indicates that the child's heart rate is slowing down, and that the heart is failing to pump blood effectively.
Choice D reason: This is the correct statement, as irritability, tachycardia, and poor peripheral perfusion are signs of compensated shock. These indicate that the child is experiencing anxiety and discomfort, that the heart is beating faster to maintain blood pressure, and that the blood vessels are constricting to divert blood to vital organs.
Correct Answer is B
Explanation
Choice A reason: Placing the infant in Trendelenburg position (head lower than feet) after eating is not a good suggestion to minimize reflux. This position may increase the abdominal pressure and the risk of aspiration. The infant should be placed in an upright or semi-upright position (30 to 45 degrees) for at least 30 minutes after feeding to reduce reflux and prevent regurgitation¹.
Choice B reason: Thickening the formula with rice cereal is a common and effective suggestion to minimize reflux. The rice cereal increases the viscosity and weight of the formula, making it less likely to flow back into the esophagus. The amount of rice cereal added should be about 1 teaspoon per ounce of formula, unless otherwise instructed by the health care provider².
Choice C reason: Giving continuous nasogastric tube feedings is not a necessary or desirable suggestion to minimize reflux. Nasogastric tube feedings are used for infants who have severe reflux and cannot tolerate oral feedings, or who have other medical conditions that require tube feeding. Nasogastric tube feedings may have complications such as infection, irritation, displacement, or obstruction of the tube. They may also interfere with the infant's oral development and bonding with the caregiver³.
Choice D reason: Giving larger, less frequent feedings is not a helpful suggestion to minimize reflux. Larger feedings may overfill the stomach and increase the pressure on the lower esophageal sphincter, which is the muscle that prevents reflux. Less frequent feedings may also make the infant more hungry and irritable, and cause more crying and swallowing of air. The infant should be given smaller, more frequent feedings to reduce reflux and promote digestion.
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