A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?
Formula should be changed to whole milk when the infant is 9 months old.
Formula that remains in the bottle should be used for one more feeding.
If the infant turns away after taking most of the feeding, stop the feeding.
If the infant is gaining weight too rapidly, dilute the formula.
The Correct Answer is C
Choice A reason: Formula should not be changed to whole milk until the infant is 12 months old, as whole milk does not provide enough iron and other nutrients for the infant's growth and development. Whole milk can also cause intestinal bleeding and increase the risk of allergies in infants younger than 12 months.
Choice B reason: Formula that remains in the bottle should not be used for another feeding, as it can harbor bacteria and cause infection. Any formula that is not consumed within one hour of preparation or feeding should be discarded.
Choice C reason: If the infant turns away after taking most of the feeding, it is a sign that the infant is full and satisfied. The nurse should instruct the parents to stop the feeding and burp the infant. Forcing the infant to finish the bottle can cause overfeeding and vomiting.
Choice D reason: If the infant is gaining weight too rapidly, diluting the formula is not a safe or effective solution. Diluting the formula can cause water intoxication, electrolyte imbalance, and malnutrition in the infant. The nurse should advise the parents to consult with the infant's doctor about the appropriate amount and type of formula for the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Anticholinesterase medications should be taken 30 minutes before meals, not with meals. This is because they enhance the action of acetylcholine, which improves muscle strength and swallowing ability.
Choice B reason: Positioning the head of the client's bed to 40° while eating helps prevent aspiration and facilitates swallowing. This is the best action for the nurse to take for a client who has myasthenia gravis.
Choice C reason: Encouraging the client to lie down after eating is not advisable, as it increases the risk of aspiration and reflux. The client should remain upright for at least 30 minutes after eating.
Choice D reason: Providing the client with food cut into small bites is not enough to ensure safe and adequate nutrition. The client may still have difficulty swallowing and chewing. The nurse should also offer soft, moist, and easy-to-swallow foods, and avoid foods that are dry, sticky, or hard.
Correct Answer is B
Explanation
Choice A reason: Changing the feeding to a continuous infusion may not improve the constipation, as it does not address the fluid deficit or the fiber content of the formula. Continuous infusion may also increase the risk of aspiration, diarrhea, and bacterial contamination¹.
Choice B reason: Increasing the amount of free water can help prevent or treat constipation by hydrating the stool and facilitating its passage. The client's fluid intake and output indicate a fluid deficit, which can contribute to constipation. The recommended fluid intake for adults is 30 to 35 mL/kg/day².
Choice C reason: Decreasing the infusion rate of feeding may worsen the constipation, as it reduces the caloric and fluid intake of the client. The infusion rate should be based on the client's nutritional needs and tolerance¹.
Choice D reason: Requesting a prescription for a diuretic is not appropriate, as it would further dehydrate the client and aggravate the constipation. Diuretics are indicated for clients with fluid overload, not fluid deficit³.
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