A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?
Intraventricular hemorrhage
Need for placement of a gastrostomy tube
Overstimulation
Necrotizing enterocolitis
The Correct Answer is D
A. Intraventricular hemorrhage presents with neurological signs like apnea or seizures, not primarily gastrointestinal symptoms.
B. Increased gastric residuals alone may indicate a need for tube placement, but the full symptom set suggests NEC.
C. Overstimulation may cause irritability but does not typically result in bloody stools or abdominal distension.
D. NEC is a life-threatening gastrointestinal disorder in preterm infants characterized by intestinal inflammation, abdominal distension, lethargy, bloody stools, and increased gastric residuals. Immediate intervention is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using a whole hand for gentle containment is more appropriate for calming preterm infants.
B. Promoting flexion, not extension, helps mimic the fetal position and provides comfort.
C. A dimly lit environment is preferred for preterm infants to reduce sensory overload.
D. Clustering care reduces stimulation and promotes rest, which is essential for preterm infant development and reducing stress.
Correct Answer is B
Explanation
A. Ice packs after feeding can help reduce swelling and provide comfort for engorgement.
B. Applying hot packs during breastfeeding can increase blood flow and potentially make engorgement worse. Cold packs or ice are typically recommended after breastfeeding to reduce swelling and discomfort from engorgement.
C. Cabbage leaves are sometimes used as a natural remedy for engorgement, as they can help reduce inflammation and discomfort.
D. Breastfeeding every 2 hours is a recommended practice to help relieve engorgement and establish milk supply.
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