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 D
Explanation
A. Comparing the child's vital signs over the past three weeks (option A) may not provide significant information about the underlying cause of his symptoms, as vital signs are unlikely to directly indicate stress or emotional distress.
B. Counseling the parents to pay more attention to the child (option B) is a general suggestion and may not be the most effective way to address the specific issues he is facing. It's important to identify the underlying causes and stressors first.
C. Conducting a complete neurological assessment (option C) is not warranted at this stage, as the child's symptoms are more likely related to emotional or psychological factors rather than a neurological problem. Gathering information about his school experiences would be a more appropriate initial step.
D. Ask the boy to describe a typical day at school.
The child's reported symptoms, including headaches, stomach aches, and difficulty sleeping, may be indicative of stress or emotional issues. To better understand and address the underlying cause of these symptoms, it's important to gather more information about the child's daily experiences. By asking the boy to describe a typical day at school (option D), the nurse can uncover potential stressors or challenges he may be facing, such as academic difficulties, bullying, social issues, or other stressors that might be contributing to his symptoms.
Correct Answer is ["A","D","E","F"]
Explanation
A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.
D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.
E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.
F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.
B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.
The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.
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