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 D
Explanation
Choice A rationale
While surgery can provide a visualization of other pathology and dysfunction of the kidney, this is not the primary reason for performing surgery before a biopsy in the case of Wilms’ tumor.
Choice B rationale
Although staging the tumor and determining metastasis to other sites is an important part of the treatment process, it is not the main reason for performing surgery before a biopsy in the case of Wilms’ tumor.
Choice C rationale
While metal clips may be surgically applied at the tumor site for exact marking for radiation in some cases, this is not the primary reason for performing surgery before a biopsy in the case of Wilms’ tumor.
Choice D rationale
The main reason for performing surgery before a biopsy in the case of Wilms’ tumor is that a biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.
Correct Answer is A
Explanation
Choice A rationale
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the right leg. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage. Changes in peripheral pulses and sensation can indicate potential complications, such as compromised blood flow or nerve compression, which need immediate attention to prevent further damage.
Choice B rationale
While cleansing pin sites as prescribed is important for infection prevention, it is not the most critical intervention in the context of assessing vascular and neurologic status.
Choice C rationale
Assessing skin for redness and signs of tissue breakdown is important for skin care and preventing pressure ulcers, but it is secondary to monitoring peripheral pulses and sensations when the child is in traction.
Choice D rationale
Changing position every 2 hours is a standard nursing practice to prevent pressure ulcers and provide comfort, but it does not take precedence over monitoring circulation and sensation in the affected limb.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today