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
Explanation
Choice A rationale:
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a pain assessment tool commonly used for infants and young children who cannot verbalize their pain. It assesses different behavioral and physiological indicators of pain, such as facial expressions, leg movement, activity level, crying, and response to consoling. Given that the infant is only 18 months old, this scale is appropriate for evaluating their postoperative pain.
Choice B rationale:
The Color tool is not a recognized pain assessment tool. It's essential to use validated and standardized pain assessment scales, and the Color tool does not fit this criterion.
Choice C rationale:
The Poker Chip Tool is not typically used for pain assessment in infants. It's often used with older children to assess pain intensity using a poker chip set that corresponds to different levels of pain. However, for an 18-month-old infant, behavioral assessments like the FLACC scale would be more suitable.
Choice D rationale:
The Numeric scale involves asking the patient to rate their pain on a numerical scale, often from 0 to 10. However, this scale is not appropriate for an 18-month-old infant who is likely unable to comprehend or use numbers to express their pain. The FLACC scale provides a more comprehensive assessment of pain in non-verbal or preverbal children.
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