A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings.
To maintain normal growth and development of the infant, which action should the nurse include?
Offer a pacifier for non-nutritive sucking.
Use sterile technique during feedings.
Ensure placement of the nasogastric tube with an abdominal x-ray.
Speak to the healthcare provider about instituting physical therapy.
The Correct Answer is A
Choice A rationale
Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.
Choice B rationale
Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.
Choice C rationale
While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.
Choice D rationale
Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.
Choice B rationale
Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.
Choice C rationale
Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.
Choice D rationale
Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.
Correct Answer is D
Explanation
Choice A rationale
Iron is essential for preventing anemia, particularly in pregnant women, but it does not prevent neural tube defects like anencephaly. Iron supports overall maternal and fetal health but is not specific to preventing congenital anomalies.
Choice B rationale
Calcium is crucial for fetal bone development and maternal bone health, but it does not play a role in preventing anencephaly. Adequate calcium intake is important during pregnancy but is not linked to neural tube defect prevention.
Choice C rationale
Vitamin D is important for bone health and immune function but does not prevent neural tube defects. Sufficient vitamin D levels are necessary for the mother's and baby's health but are not related to anencephaly prevention.
Choice D rationale
Folic acid is the correct choice as it has been shown to prevent neural tube defects, including anencephaly and spina bifida. It is recommended that women of childbearing age take folic acid supplements before conception and during early pregnancy to reduce the risk of these congenital anomalies.
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