A nurse is contributing to the plan of care for an infant who has heart failure. Which of the following interventions should the nurse recommend?
Provide feedings every 3 hr.
Dilute formula to half strength.
Place the infant in lateral position during feeding.
Implement bolus gavage feedings.
The Correct Answer is A
A. Infants with heart failure may experience fatigue during feeding, so smaller, more frequent feedings are recommended to prevent exhaustion and ensure adequate nutrition. Feedings every 3 hours are typically recommended to maintain a steady intake without overexertion.
B. Diluting formula to half strength is not recommended for an infant with heart failure, as it can lead to malnutrition and insufficient caloric intake. The formula should be provided at normal strength.
C. Placing the infant in a lateral position during feeding could be unsafe, as it may increase the risk of aspiration. The infant should generally be fed in an upright or semi-upright position to reduce aspiration risk and promote optimal digestion.
D. Bolus gavage feedings are typically used for infants who are unable to feed orally due to medical conditions, but for a child with heart failure who is feeding orally, more frequent and smaller feedings would be preferable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Removing outer clothing can be uncomfortable or distressing for toddlers, so it is often better to do this gradually, allowing the child to feel more at ease.
B. Allowing the toddler to sit in the parent's lap can provide comfort and security during the examination.
C. Allowing the toddler to inspect the stethoscope is an effective way to reduce anxiety and establish trust with the child.
D. Traumatic procedures, such as immunizations or blood draws, should be done last to avoid causing unnecessary distress during the examination.
Correct Answer is B
Explanation
A. Neck flexion when bending forward is not a typical indicator of scoliosis. Scoliosis is identified by abnormal curvature of the spine, not by the neck.
B. Uneven shoulders when standing erect are a key indicator of scoliosis. This asymmetry can be identified when the child bends forward at the waist, which is a standard test for scoliosis during a physical examination.
C. Toes that point inward when bending forward is not a sign of scoliosis. This could be indicative of a different musculoskeletal issue such as hip or leg alignment problems, but it is not related to scoliosis.
D. Knees that bow outward when standing erect indicate bow-leggedness (genu varum), not scoliosis. Scoliosis specifically affects the spine's curvature.
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