A nurse is contributing to the plan of care for a toddler who is receiving intermittent enteral feedings. Which of the following interventions should the nurse include?
Maintain the child in a supine position.
Discard gastric residuals prior to each feeding
Warm the feeding in the microwave oven for 15 seconds
Administer the feeding to the child at 10 mL/min.
The Correct Answer is D
A. Maintain the child in a supine position: The child should not be in a supine (lying flat) position during enteral feedings, as this increases the risk of aspiration. The child should be positioned upright or at least 30 to 45 degrees to reduce this risk.
B. Discard gastric residuals prior to each feeding: While it is important to check gastric residuals before each feeding to ensure proper gastric emptying, residuals should not automatically be discarded. Depending on the volume of residuals, the feeding may need to be delayed or adjusted rather than discarded.
C. Warm the feeding in the microwave oven for 15 seconds: Feeding should never be warmed in the microwave because it can cause uneven heating, which could lead to burns. Feedings should be warmed using a safe method, such as a warm water bath, to ensure even temperature.
D. Administer the feeding to the child at 10 mL/min: Administering the feeding at a slow and controlled rate, such as 10 mL/min, is recommended to prevent discomfort and reduce the risk of aspiration. This rate allows the digestive system to process the feeding properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Collect a stool specimen for occult blood: A stool specimen for occult blood is typically used to check for hidden blood in the stool, which might suggest conditions like gastrointestinal bleeding or certain infections. It is not the primary test for diagnosing C. difficile infection.
B. Draw a blood culture: Blood cultures are used to identify bacteria or other pathogens in the blood, but they are not appropriate for diagnosing Clostridium difficile infection, which primarily affects the gastrointestinal system.
C. Conduct a tape test: A tape test is used for diagnosing pinworm infections, not for Clostridium difficile. It involves placing a piece of tape on the child's anal area to collect eggs for examination under a microscope. It is not relevant to the suspicion of C. difficile.
D. Obtain a stool specimen for culture: The most appropriate action is to collect a stool specimen for culture to identify C. difficile. The diagnosis of C. difficile infection is typically confirmed by stool testing, which may include testing for toxins produced by the bacteria.
Correct Answer is B
Explanation
A. Induce fatigue with vigorous activities close to bedtime: Engaging in vigorous activities close to bedtime can overstimulate the toddler, making it harder for them to wind down and fall asleep. It’s best to avoid stimulating activities in the hour or so before bedtime.
B. Provide the toddler with a light snack before bedtime: A light snack before bedtime can be helpful, as it may prevent hunger from interfering with sleep. The snack should be something that won't cause discomfort or disrupt digestion, like a small piece of fruit or crackers.
C. Allow the toddler to choose their bedtime: While some level of flexibility can be beneficial, allowing a toddler to choose their bedtime may lead to inconsistency and difficulty establishing a healthy sleep routine. A set bedtime helps toddlers establish good sleep habits.
D. Permit the toddler to watch television in bed to promote sleep: Watching television in bed can be overstimulating and interfere with the toddler’s ability to fall asleep. It’s best to have a calm, quiet environment before bedtime to help the child relax and prepare for sleep.
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