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
Diaphragmatic respirations are not typically associated with acute respiratory distress in a child with respiratory syncytial virus (RSV). Diaphragmatic respirations are normal in infants and young children.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and would not typically indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and would not typically indicate acute respiratory distress in a child with RSV45.
Choice D rationale
Flaring of the nares, or nostrils, can be a sign of respiratory distress in infants and young children. It indicates that the child is using additional muscles to breathe, which can occur when the lower airways are blocked or narrowed, as in a severe RSV infection.
Correct Answer is D
Explanation
The correct answer is choice d. Positive rapid strep test of the oropharynx.
Choice A rationale:
Blood pressure of 88/50 mmHg is lower than normal but not typically associated with acute glomerulonephritis. High blood pressure is more common in this condition.
Choice B rationale:
Weight loss is not a typical symptom of acute glomerulonephritis. Instead, fluid retention and weight gain are more common due to edema.
Choice C rationale:
A maculopapular rash over the trunk is not commonly associated with acute glomerulonephritis. This condition usually presents with symptoms like hematuria, proteinuria, and edema.
Choice D rationale:
A positive rapid strep test of the oropharynx indicates a recent streptococcal infection, which is a common cause of acute glomerulonephritis. Reporting this finding is crucial for appropriate management.
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