A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in plan of care?
Ensure placement of the enteral tube with an abdominal x-ray.
Speak to the healthcare provider about instituting physical therapy.
Offer a pacifier for non-nutritive sucking.
Use sterile technique during feedings.
The Correct Answer is C
A. Ensure placement of the enteral tube with an abdominal x-ray: Verifying enteral tube placement is essential for safety, but it is not related to maintaining the newborn's growth and development. Tube placement should already have been verified prior to initiating feedings.
B. Speak to the healthcare provider about instituting physical therapy: Physical therapy may be beneficial for infants with specific motor delays, but it is not a routine intervention for all infants recovering from gastroschisis.
C. Offer a pacifier for non-nutritive sucking: Non-nutritive sucking (e.g., using a pacifier) is crucial for the growth and development of newborns, especially those unable to feed orally. It helps promote oral-motor development, soothes the infant, and lays the foundation for transitioning to oral feeding. This is particularly important for an infant receiving parenteral or enteral nutrition to ensure they develop the skills and comfort needed for future oral feeding.
D. Use sterile technique during feedings: Clean technique is generally sufficient or routine enteral feedings unless there is a specific indication for sterility (e.g., immunocompromised clients). Further, this does not directly support growth and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B"}
Explanation
Across the ventricular septum: This clarifies the location of the shunt, indicating that it occurs across the ventricular septum, leading to the mixing of oxygenated and deoxygenated blood.
So, the complete statement is: "Based on the child's diagnosis, he has mixed blood flow due to a left-to-right shunt across the ventricular septum."
Correct Answer is A
Explanation
A. Digoxin:Digoxin is a cardiac glycoside that can cause toxicity if the heart rate is too low. For infants, the apical pulse should typically be greater than 90-110 beats per minute before administration. Since this infant has an apical pulse of 88 beats/minute, the nurse should withhold digoxin and notify the healthcare provider for further evaluation.
B. Enalapril:Enalapril is an ACE inhibitor used to treat heart failure and hypertension. It can generally be administered as prescribed, regardless of the current heart rate, but blood pressure should be monitored.
C. Furosemide:Furosemide is a diuretic commonly used in heart failure management to reduce fluid overload. It can be administered safely at this time, as it does not have the same pulse considerations as digoxin.
D. Hydralazine:Hydralazine is a vasodilator used to manage hypertension and improve cardiac output. It can be administered without concern for the current heart rate, although blood pressure should be monitored.
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