A nurse is providing teaching to the parent of a newborn who is 1 day old and has a prescription for gavage feeding.
Which of the following information should the nurse include in the teaching?
Administer 20 mL per feeding.
Place the newborn in a supine position after feedings.
Feedings may occur in clusters.
Feedings should be accompanied by nonnutritive sucking.
The Correct Answer is D
Choice A rationale
The specific volume of formula for gavage feeding a newborn, such as 20 mL, depends on the newborn's weight, gestational age, and clinical condition. A blanket recommendation of 20 mL without this individualized assessment is inappropriate and could lead to over or underfeeding, impacting growth and gastrointestinal tolerance.
Choice B rationale
Placing a newborn in a supine position immediately after gavage feedings increases the risk of aspiration, especially for infants with immature swallowing reflexes or reflux. The newborn should be positioned on their right side or semi-Fowler's position to facilitate gastric emptying and minimize aspiration risk.
Choice C rationale
While cluster feeding (multiple feedings close together) is a natural pattern for some breastfed infants, for gavage feeding, regular, scheduled intervals are typically maintained to ensure consistent nutrient delivery and proper digestion, especially in newborns who are medically fragile. Cluster feeding is not a standard gavage feeding practice.
Choice D rationale
Nonnutritive sucking (e.g., pacifier use) during gavage feedings is crucial for promoting oral motor development and associating the feeling of fullness with sucking. This helps prevent oral aversion and prepares the newborn for eventual oral feeding, stimulating gastric secretions and improving digestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Polyuria, an abnormally large production of urine, is not a typical adverse effect of epidural analgesia. Epidural analgesia, due to its influence on sympathetic nervous system blockade, can sometimes lead to urinary retention by inhibiting bladder detrusor muscle contraction and relaxing the urethral sphincter. Therefore, polyuria would be an unexpected finding.
Choice B rationale
A maternal temperature of 37.4° C (99.4° F) is within the normal physiological range for a laboring client. Slight elevations can occur due to the metabolic demands of labor or dehydration, but this temperature does not indicate an adverse effect directly attributable to epidural analgesia. Fever, defined as a temperature above 38° C (100.4° F), can be associated with epidural use due to thermoregulatory changes.
Choice C rationale
A fetal heart rate of 152/min is within the normal range for a term fetus, typically 110-160 beats per minute. This finding indicates a healthy fetal response and does not suggest an adverse effect of epidural analgesia. Epidural analgesia itself usually does not directly alter the fetal heart rate in a negative way if maternal hemodynamics remain stable.
Choice D rationale
Hypotension is a common adverse effect of epidural analgesia. It occurs due to sympathetic blockade, which causes vasodilation and peripheral pooling of blood, leading to decreased venous return to the heart and a subsequent drop in cardiac output and blood pressure. This reduction in blood pressure can compromise uteroplacental perfusion.
Correct Answer is D
Explanation
Choice A rationale
Urinary output of 20 mL/hr is indicative of oliguria, which is a significant adverse effect of magnesium sulfate therapy. Magnesium is renally excreted, and decreased urinary output can lead to magnesium toxicity. The desired urinary output for a client receiving magnesium sulfate should be at least 25 to 30 mL/hr to ensure adequate drug excretion.
Choice B rationale
Fetal heart rate pattern with minimal variability is a concerning finding and can indicate central nervous system depression in the fetus, potentially due to excessive magnesium levels. Normal fetal heart rate variability reflects a healthy autonomic nervous system. Magnesium sulfate's therapeutic effect is on the mother, not directly on fetal heart rate variability.
Choice C rationale
A change in fetal heart rate from 150/min to 166/min, while still within the normal range (110-160 bpm), does not directly indicate the desired therapeutic effect of magnesium sulfate for preeclampsia. This fluctuation could be due to various factors and is not a primary indicator of successful seizure prophylaxis or blood pressure control.
Choice D rationale
Magnesium sulfate is a central nervous system depressant that works by blocking neuromuscular transmission, thereby reducing hyperreflexia associated with preeclampsia. A decrease in deep tendon reflexes from 4+ (hyperactive) to 2+ (normal) indicates that the medication is achieving its desired therapeutic effect of central nervous system depression and reducing seizure risk.
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