A nurse is assessing a school-age child's cranial nerve function.
Which of the following actions should the nurse ask the child to take when assessing the accessory nerve?

Choice A rationale:

Lack of sleep is a common trigger that increases the risk of seizures in individuals with a seizure disorder. Sleep deprivation can lower the seizure threshold, making individuals more susceptible to seizures. Educating the guardians about the importance of maintaining a regular sleep schedule for the child can help minimize the risk of seizures.

Choice Brationale:

Decreased temperature is not a common trigger for seizures. In fact, high fever, rather than decreased temperature, is associated with febrile seizures in children. Febrile seizures are triggered by a rapid increase in body temperature.

Choice Crationale:

Exposure to secondhand smoke is a trigger for respiratory issues but is not directly linked to seizures. While it is essential to educate families about the dangers of secondhand smoke, it is not a specific trigger for seizures.

Choice D rationale:

Prolonged headache is not a trigger for seizures. However, it could be a symptom of an underlying neurological issue, and individuals experiencing persistent headaches should seek medical evaluation for proper diagnosis and management.

Choice A rationale: Offering the infant a pacifier during feedings can help with non-nutritive sucking, which is beneficial for the development of oral motor skills. It can also provide comfort and a sense of normalcy for the infant during tube feedings. This practice is encouraged to promote positive feeding experiences and support the infant's overall development.

Choice B rationale: Placing the infant in a supine position during feedings is not recommended due to the increased risk of aspiration. The preferred position is to keep the infant in an upright or semi-upright position to facilitate proper digestion and reduce the risk of gastroesophageal reflux and aspiration. Proper positioning is crucial for the safety and well-being of the infant during enteral feedings.

Choice C rationale: Heating the formula to 39°C (102°F) is not advised as it can be too hot and cause burns or discomfort to the infant. The formula should be administered at room temperature or slightly warmed to body temperature to ensure it is safe and comfortable for the infant. Proper temperature regulation is important to prevent thermal injuries.

Choice D rationale: Checking for residual volumes by aspirating stomach contents is an important step in assessing the infant's tolerance to the feeding. It helps determine if the previous feeding has been adequately digested and can indicate potential issues such as delayed gastric emptying. Regular assessment of residual volumes is a standard practice in managing enteral feedings for infants.

Choice E rationale: Instilling the formula over a period of 30 to 45 minutes is recommended to mimic normal feeding patterns and promote proper digestion. Slow and controlled administration of the feeding reduces the risk of gastrointestinal discomfort and aspiration. It also allows for better tolerance and absorption of the nutrients in the formula.