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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because postmature babies lose the protective vernix that covers their skin in utero, and their skin becomes dry and cracked.Postmature babies also have less subcutaneous fat, which makes them look thin and wrinkled.
Choice A is wrong because postmature babies have less body fat than term babies, not more.They use up their fat stores to survive in the womb beyond 42 weeks of gestation.
Choice B is wrong because postmature babies have well-developed breast buds and areola, not flat ones.Breast development is a sign of fetal maturity that occurs around 36 weeks of gestation.
Choice C is wrong because postmature babies have less flexibility in their joints and muscles, not more.They have less amniotic fluid to cushion their movements, and their bones become more ossified as they grow older.
Normal ranges for gestational age are 37 to 42 weeks.Babies born before 37 weeks are considered preterm, and babies born after 42 weeks are considered postmature.
Correct Answer is B
Explanation
A normal blood glucose level for a healthy term newborn is between 30 and 60 mg/dL.This range is lower than that of older children and adults, because newborns are adapting to life outside the womb and their glucose levels rise gradually after birth.
Choice A is wrong because 10 and 30 mg/dL is too low for a newborn and indicates hypoglycemia, which can cause symptoms such as jitteriness, poor feeding, lethargy, and cyanosis.
Choice C is wrong because 60 and 90 mg/dL is too high for a newborn and indicates hyperglycemia, which can cause symptoms such as dehydration, poor feeding, irritability, and seizures.
Choice D is wrong because 90 and 120 mg/dL is also too high for a newborn and indicates hyperglycemia, which can have the same consequences as choice C.
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