A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?
Educate the infant's caregiver about the feeding.
Flush the feeding tube before the feeding.
Clarify the feeding prescription with the provider.
Place a label on the feeding bag and tubing.
The Correct Answer is C
A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Feed infant in a supine position: Contraindicated
- Supine feeding increases the risk of aspiration and exacerbates reflux.
Offer smaller, more frequent feedings: Appropriate
- Smaller, frequent feedings reduce gastric distension and reflux episodes.
Thicken formula feedings with rice cereal: Appropriate
- Thickened feedings can help reduce reflux by increasing the weight of the stomach contents.
Place infant in a side-lying position for sleep: Contraindicated
- The recommended sleep position for infants is supine (on the back) to reduce the risk of sudden infant death syndrome (SIDS).
Correct Answer is A
Explanation
A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.
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