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 C

Explanation

A. Instilling 2 mL of 0.9% sodium chloride is not recommended as it can cause discomfort and does not improve the effectiveness of suctioning.
B. Sterile technique, not clean technique, should be used when suctioning a tracheostomy to prevent infection.
C. Applying suction in 3 to 4 second increments is appropriate to clear the occlusion effectively without causing trauma to the trachea.
D. The catheter should not fit snugly into the tracheostomy tube; it should be small enough to fit comfortably to avoid trauma and ensure effective suctioning.

A. A 6-year-old child who has a fracture of the arm from a bicycle injury B. A 34-month-old child who has several small bruises on the shins C. A 4-year-old child who has a history of frequent urinary tract infections D. A 15-month-old child who bites other children while at day care

Correct Answer is C

Explanation

A. A fracture from a bicycle injury is consistent with common childhood accidents and does not necessarily indicate maltreatment.
B. Small bruises on the shins of a toddler are typical as they learn to walk and play and are not necessarily a sign of maltreatment.
C. Frequent urinary tract infections in a young child can be a sign of sexual abuse or neglect and should be reported for further investigation. This pattern is concerning and warrants further evaluation by a healthcare provider.
D. Biting behavior in toddlers is relatively common and part of normal development. It does not necessarily indicate maltreatment.

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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

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