A nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics.
The infant expels a bloody stool.
What nursing action should the nurse implement?
Obtain a rectal temperature.
Institute contact precautions.
Decrease the amount of the feeding.
Assess for abdominal distention.
The Correct Answer is B
Institute contact precautions. This is because the infant may have necrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.
NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death. NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.
Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool. Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.
Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.
The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals. Decreasing the feeding may also compromise the infant’s growth and development.
Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.
Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition. Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Increased oxygen saturation.This indicates that the condition is improving because it means that the blood is getting more oxygen in the lungs and less blood is shunting from the aorta to the pulmonary artery through the patent ductus arteriosus (PDA).
Choice A is wrong because decreased heart rate can be a sign of hypoxia, acidosis, or heart failure, which are complications of PDA.
Choice B is wrong because increased blood pressure can be a sign of increased systemic vascular resistance, which can result from decreased tissue perfusion due to PDA.
Choice C is wrong because decreased respiratory rate can be a sign of respiratory depression, which can be caused by some medications used to treat PDA, such as indomethacin or ibuprofen.
Normal ranges for oxygen saturation in preterm infants are between 88% and 95%.
Normal ranges for heart rate in preterm infants are between 120 and 160 beats per minute.
Normal ranges for blood pressure in preterm infants depend on gestational age and weight.
Normal ranges for respiratory rate in preterm infants are between 40 and 60 breaths per minute.
Correct Answer is A
Explanation
This is because phototherapy can damage the baby’s eyes and cause retinal injury.Eye pads should be used to protect the baby’s eyes from the light and should be removed every 4 hours to check for infection or injury.
Choice B is wrong because turning the lights off for ten minutes every hour would reduce the effectiveness of phototherapy and prolong the treatment time.Phototherapy aims to expose the baby’s skin to as much light as possible.
Choice C is wrong because clothing the baby in a shirt and diaper only would limit the amount of skin exposed to the light.The baby should be naked or wear only a diaper during phototherapy.
Choice D is wrong because tightly swaddling the baby in a baby blanket would also limit the amount of skin exposed to the light and increase the risk of overheating.The baby should be loosely wrapped or uncovered during phototherapy.
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