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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Sun protection is necessary even when using self-tanning creams. Self-tanning creams do not provide protection against the harmful effects of ultraviolet (UV) radiation. Adolescents should be educated about the importance of using sunscreen to prevent skin damage and reduce the risk of skin cancer.
Choice B rationale:
The risk of injury from firearms does not necessarily decrease as children enter adolescence. Adolescents may still lack proper judgment and decision-making skills, making them susceptible to accidents and injuries related to firearms. Educating adolescents about firearm safety and promoting responsible firearm storage is essential.
Choice C rationale:
(Correct Choice) Driving skills can indeed be impaired when friends are present. Teenagers often face distractions while driving, especially when friends are in the car. Peer pressure and social interactions can divert their attention from the road, leading to an increased risk of accidents. Educating adolescents about the importance of focused and responsible driving can help reduce this risk.
Choice D rationale:
Medroxyprogesterone, a form of hormonal contraception, does not provide protection against gonorrhea. It offers contraception by preventing ovulation and altering the cervical mucus to impede sperm penetration. However, it does not offer any protection against sexually transmitted infections (STIs). Adolescents should be educated about safe sex practices to prevent STIs.
Correct Answer is A
Explanation
Choice A rationale:
Administer two puffs of albuterol. This is the correct answer because albuterol is a bronchodilator that helps to relieve acute asthma symptoms by opening up the airways. In a child experiencing difficulty breathing due to asthma, prompt administration of albuterol can help alleviate the symptoms and improve breathing.
Choice B rationale:
Place the child in the supine position. Placing the child in the supine position can further compromise their breathing, especially in a situation of asthma exacerbation. This position can restrict the airways and make breathing more difficult, so it is not an appropriate action.
Choice C rationale:
Encourage the use of a flutter mucus clearance device. While mucus clearance devices can be helpful for individuals with chronic respiratory conditions, such as cystic fibrosis, it is not the priority action for a child experiencing acute asthma symptoms. The immediate focus should be on relieving the airway constriction and addressing the breathing difficulty.
Choice D rationale:
Instruct the child to perform controlled breathing exercises. Controlled breathing exercises might be useful for anxiety and panic management, but in an acute asthma episode, the child's primary need is to open up the airways and improve breathing. Albuterol administration takes precedence over breathing exercises in this situation.
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