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.
The Correct Answer is A
A. Infants with HF tire easily; feeding them early, before they are overly fatigued and crying, conserves energy and helps them take in more nutrition. Smaller, more frequent feedings are often recommended.
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. Thickened feeds are sometimes used for reflux, not HF. Adding cereal increases caloric intake but also makes sucking/swallowing more difficult, increasing energy expenditure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Drawing a blood culture is not indicated for suspected Clostridium difficile, as it is a gastrointestinal infection.
B. A stool specimen for occult blood is not specific for diagnosing Clostridium difficile.
C. Obtaining a stool specimen for culture is the appropriate action to diagnose Clostridium difficile, as it will identify the presence of the bacteria.
D. A tape test is used to detect pinworms, not Clostridium difficile.
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.
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