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 A
Explanation
A. Logrolling is a specific turning technique used to maintain spinal alignment post-operatively. It requires two nurses to prevent injury to the spine.
B. While elevating the head of the bed is important to prevent respiratory complications, a 30° angle is too high for a patient with spinal instrumentation. A lower angle is typically recommended to maintain spinal alignment.
C. Early ambulation is encouraged after surgery, but 12 hours is too soon. The adolescent will likely be on bed rest for several days to allow the fusion to stabilize.
D. Clear liquids are often introduced earlier than 4 hours post-surgery, once bowel sounds return and there is no evidence of nausea or vomiting.
Correct Answer is A
Explanation
A. A quick-release knot allows for the restraints to be removed swiftly in case of an emergency. This is important to ensure that the child can be freed quickly if needed, such as if there is a sudden change in the child’s condition or an emergency arises.
B. This is not adequate for ensuring the child’s safety. Regular assessments are critical for monitoring the child's physical condition, circulation, and overall comfort while in restraints. Typically, the child should be assessed at least every 15-30 minutes, depending on the facility’s policy and the child’s condition, to prevent complications such as skin breakdown, impaired circulation, or increased distress.
C. The renewal of a restraint order typically must occur more frequently than every 48 hours. According to most regulations and facility policies, restraint orders are usually valid for a shorter period, often 24 hours, and must be renewed daily by a provider.
D. This is not appropriate and can be dangerous. Restraints should never be tied to bed rails because this can cause serious injury if the child moves or if there is any sudden movement of the bed. Instead, restraints should be secured to a part of the bed frame that moves with the bed and does not pose a risk of injury. Proper restraint attachment helps avoid entrapment and injury.
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