A nurse is caring for a 3-month-old infant who has a cleft of the soft palate.
Which of the following actions should the nurse take?
Discontinue feeding if the infant's eyes become watery.
Postpone burping the infant until after completing each feeding.
Elevate the infant's head to a 10° angle during feedings.
Feed the infant 177.4 mL (6 oz) of formula three times each day.
Feed the infant 177.4 mL (6 oz) of formula three times each day.
The Correct Answer is C
The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings.
This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.
Choice A is wrong because watery eyes are not an indication to discontinue feeding.
Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.
Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The trigeminal nerve is responsible for sensation in the face and motor functions such as biting and chewing.
Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve.
Choice A is wrong because it assesses the vestibulocochlear nerve, not the trigeminal nerve.
Choice C is wrong because it assesses the glossopharyngeal and vagus nerves, not the trigeminal nerve.
Choice D is wrong because it assesses the olfactory nerve, not the trigeminal nerve.
Correct Answer is D
Explanation
An increased respiratory rate is a sign of severe dehydration in infants.
Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function.
Choice A is wrong because hypertension is not a sign of severe dehydration in infants.
Choice B is wrong because increased urine output is not a sign of severe dehydration in infants.
In fact, decreased urine output is a sign of dehydration 2.
Choice C is wrong because a capillary refill of 2 seconds is normal and not a sign of severe dehydration in infants.
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