A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?
Place the infant in a recumbent position during feeding.
Allow the infant 45 min for each feeding.
Allow the infant to self-soothe by crying prior to feeding.
Implement a 3-hr feeding schedule.
The Correct Answer is D
A. Infants with heart failure often experience increased respiratory effort when lying flat. Placing them in a recumbent position can worsen their condition by making it harder to breathe. An upright or semi- upright position is usually preferred to facilitate breathing and digestion.
B. Infants with heart failure often tire easily during feeding due to increased metabolic demands. Prolonged feedings can be exhausting and may lead to insufficient intake. Shorter, more frequent feedings are typically recommended.
C. Crying increases the infant's oxygen consumption and metabolic rate, which can be detrimental for an infant with heart failure. It is essential to prevent crying and distress before feeding.
D. Infants with heart failure often tire easily. A more frequent feeding schedule, such as every 3 hours, allows for smaller, more manageable feedings without overexerting the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The halo vest immobilizes the cervical spine completely. Any movement that might disturb the alignment of the spine is contraindicated. Using a turning sheet could potentially cause movement and damage the spine.
B. Tightening the screws without medical direction can be harmful. The screws should be checked regularly by healthcare professionals, and adjustments made as needed.
C. The entire purpose of the halo vest is to immobilize the neck. Any movement of the neck could disrupt the healing process and cause further injury.
D. Pin site care is crucial to prevent infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, drainage, or increased pain.
Correct Answer is A
Explanation
A. The doll's eye reflex, or oculocephalic reflex, is a normal reflex in infants up to about 2 months of age. It involves the eyes moving in the opposite direction of head movement. By 4 months of age, this reflex
typically disappears as the infant’s voluntary eye movements become more developed. Therefore, if the
B. By 4 months of age, it is normal for an infant to show significant reduction in head lag when pulled to a sitting position. Ideally, the infant should be able to hold their head up with minimal lag.
C. The Babinski reflex is a normal reflex in infants, where the toes fan out when the sole of the foot is stroked. This reflex is expected to be positive in infants up to about 12-24 months of age. By 4 months, a positive Babinski reflex is still normal and does not indicate a problem.
D. Infants typically start producing tears around 2-3 months of age. By 4 months, the presence of tears when crying is a normal developmental milestone and indicates healthy lacrimal gland function. Therefore, this finding is normal and does not need to be reported to the provider.
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