A nurse is caring for an infant who has heart failure and is formula-fed. Which of the following nursing interventions is appropriate to meet the infant's nutritional needs?

Feed the infant at the first sign of hunger.

Use a firm nipple on the bottle when feeding.

Dilute the formula with water to half strength.

Thicken the formula with 1 tsp of rice cereal per ounce.

Answer and Explanation

The Correct Answer is D

A. Feeding the infant at the first sign of hunger is a general good practice but does not specifically address the increased nutritional needs of an infant with heart failure.
B. A firm nipple may require more effort to suck, which can be tiring for an infant with heart failure. A softer nipple may be more appropriate.
C. Diluting the formula with water can lead to inadequate caloric intake and nutritional deficiencies. Formula should be prepared according to instructions to ensure proper nutrition.
D. Thickening the formula is often recommended to prevent regurgitation and aspiration, which can be particularly dangerous in infants with heart failure due to their compromised cardiac function.

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Correct Answer is B

Explanation

A. After administering otic medication, the child should be kept in a side-lying position on the opposite side (unaffected side) to allow the medication to flow into the ear canal properly.
B. Allowing the medication to reach room temperature before administration prevents dizziness and discomfort that can occur with cold drops. This is important for ensuring the child is comfortable and cooperates with the procedure.
C. For a 2-year-old, the ear should be gently pulled down and back to straighten the ear canal for proper administration of the medication.
D. Administering the medication with the child in an upright position is not the best method. The side-lying position allows better access to the ear canal and proper absorption of the medication.

A. Rolls from back to side B. Able to hold a rattle C. Holds arms out to be picked up D. Displays fear toward strangers

Correct Answer is B

Explanation

A. Rolling from back to side typically occurs around 4 to 5 months of age.
B. At 3 months, an infant is expected to be able to hold a rattle.
C. Holding arms out to be picked up usually develops around 7 to 9 months of age.
D. Fear toward strangers, known as stranger anxiety, typically begins around 6 to 8 months of age.

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A nurse is caring for an infant who has heart failure and is formula-fed. Which of the following nursing interventions is appropriate to meet the infant's nutritional needs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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