A nurse is preparing to administer nasogastric tube feedings to a 2-month-old infant. Which of the following actions should the nurse plan to take?
Stabilize the tube by taping it to the infant's cheek.
Position the infant in a supine position during feedings.
Aspirate residual fluid from the infant's stomach and discard.
Microwave the infant's formula to a temperature of 41° C (105.8° F).
The Correct Answer is A
Choice A rationale:
Stabilizing the nasogastric tube by taping it to the infant's cheek is a crucial step in preventing accidental removal or displacement of the tube during feedings. Infants are known for their active movements, which could lead to unintentional removal of the tube. Taping the tube securely helps maintain its proper placement and ensures the delivery of nutrients.
Choice B rationale:
Positioning the infant in a supine (lying on the back) position during feedings is not recommended. This position could lead to an increased risk of aspiration, where the feedings could enter the airway and lungs, causing respiratory issues. The recommended position for nasogastric tube feedings is semi-upright or upright to minimize this risk.
Choice C rationale:
Aspirating residual fluid from the infant's stomach and discarding it is not standard practice for nasogastric tube feedings. Aspirating can introduce the risk of infection or cause irritation to the stomach lining. Additionally, residual fluid can provide valuable information about the infant's digestion and absorption, and its presence should be taken into consideration when adjusting feedings.
Choice D rationale:
Microwaving the infant's formula to a temperature of 41°C (105.8°F) is not safe. Formula should be warmed gently using warm water or a bottle warmer to avoid overheating, which could burn the infant's mouth and esophagus. Microwaving can cause uneven heating and lead to hot spots within the formula, posing a risk of burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Maintaining oral rehydration therapy is a crucial nursing action when caring for a child with shigella, which is a bacterial infection that causes severe diarrhea. Oral rehydration therapy helps prevent dehydration and electrolyte imbalances caused by fluid loss from diarrhea. It involves giving the child oral rehydration solutions containing electrolytes and fluids to replace those lost through diarrhea.
Choice B rationale:
Providing a diet high in sodium is not recommended for a child with shigella. Shigella is associated with diarrhea and gastrointestinal symptoms, and a high-sodium diet can worsen fluid imbalances and dehydration.
Choice C rationale:
Shigella is a bacterial infection, not a viral infection, so administering antiviral medication would not be effective or appropriate. Antiviral medications are used to treat viral infections, not bacterial ones like shigella.
Choice D rationale:
Giving antidiarrheal agents every 4 hours is not recommended for a child with shigella. Antidiarrheal agents can slow down the gastrointestinal tract and inhibit the body's natural mechanism for expelling harmful substances, such as bacteria. It's important to allow the body to eliminate the bacteria and toxins causing the infection through diarrhea, while simultaneously providing rehydration support.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.
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