A newborn, who has had gastroschisis repair, is transferred to the pediatric unit after spending several days in the pediatric intensive care unit.
The infant is on parenteral nutrition and continuous enteral feedings.
What action should the nurse include in the plan of care to promote the infant’s normal growth and development?
Discuss with the healthcare provider about starting physical therapy
Offer a pacifier for non-nutritive sucking
Confirm placement of the enteral tube with an abdominal x-ray
Use sterile technique during feedings .
The Correct Answer is B
Choice A rationale
While physical therapy can be beneficial for many pediatric patients, it may not be the most appropriate intervention for a newborn who has had gastroschisis repair and is on parenteral nutrition and continuous enteral feedings. The focus at this stage should be on promoting normal growth and development, and physical therapy may not directly contribute to this goal.
Choice B rationale
Offering a pacifier for non-nutritive sucking can be an effective strategy to promote normal growth and development in infants who have had gastroschisis repair. Non-nutritive sucking can help stimulate the sucking reflex, which is important for feeding and growth. Therefore, the nurse should include this action in the plan of care.
Choice C rationale
Confirming the placement of the enteral tube with an abdominal x-ray is an important part of care for infants on continuous enteral feedings. However, this action is more related to ensuring the safety and effectiveness of the feeding process rather than promoting the infant’s normal growth and development.
Choice D rationale
Using sterile technique during feedings is a standard practice to prevent infection, especially in infants who are on parenteral nutrition and continuous enteral feedings. However, this action does not directly promote the infant’s normal growth and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal fluid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches.
Choice A rationale
While growth in height could be a positive sign of overall health and development, it does not specifically indicate that a VP shunt is functioning properly.
Choice C rationale
The presence of an intracranial pressure (ICP) monitoring probe does not indicate whether the shunt is functioning properly. The probe is a device used to measure ICP and does not provide information about the functionality of the shunt.
Choice D rationale
Being afebrile with normal vital signs postoperatively is a positive sign, but it does not specifically indicate that the shunt is functioning properly.
Correct Answer is A
Explanation
Choice A rationale
In an infant with aortic stenosis and bilateral fine crackles in both lung fields, hypotension and tachycardia are additional findings that the nurse should expect to observe. Aortic stenosis can lead to decreased cardiac output, which can result in hypotension. The body compensates for this by increasing the heart rate, leading to tachycardia.
Choice B rationale
Vigorous feeding and satiation are not typically associated with aortic stenosis. Infants with aortic stenosis may actually have difficulty feeding due to fatigue.
Choice C rationale
Fever is not a typical symptom of aortic stenosis. If an infant with aortic stenosis has a fever, it may indicate a concurrent infection.
Choice D rationale
Hemiplegia, or paralysis of one side of the body, is not a typical symptom of aortic stenosis. If an infant with aortic stenosis presents with hemiplegia, it may indicate a serious complication such as a stroke.
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