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 ["25"]
Explanation
Step 1: Calculate the total daily dose in mg: 25 kg × 10 mg/kg/day = 250 mg/day.
Step 2: Determine how many mL are needed to administer the 250 mg dose: (250 mg ÷ 50 mg) × 5 mL = (5) × 5 mL = 25 mL. Final calculated answer: 25 mL.v
Correct Answer is B
Explanation
Choice A rationale
Diet cola, although refreshing, contains caffeine which can contribute to dehydration. For adolescents with sickle cell anemia, hydration is crucial to prevent sickle cell crises. Moreover, sodas generally offer no nutritional benefits.
Choice B rationale
Lemonade is a better choice as it is hydrating and provides fluids without caffeine. Proper hydration is vital for sickle cell patients to maintain blood volume and prevent the sickling of red blood cells. Additionally, lemonade can supply essential electrolytes.
Choice C rationale
Ice tea, similar to diet cola, contains caffeine which can exacerbate dehydration. Hydration is key for individuals with sickle cell anemia to avoid complications and maintain adequate blood flow.
Choice D rationale
Milkshake, while providing hydration, is high in fat and sugar, which can be counterproductive. It also lacks the electrolytes present in lemonade which are beneficial for maintaining fluid balance in the body.
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