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
In bacterial meningitis, monitoring antibiotic levels is critical during treatment to ensure therapeutic effectiveness and avoid toxicity. However, it is not necessary to check antibiotic levels after completing the course. The body clears the antibiotics within a few days, and monitoring is more relevant during therapy.
Choice B rationale
While monitoring wet diapers is important during illness, it's not necessary to continue strict monitoring post-treatment. Wet diapers track hydration and renal function, which should normalize after successful treatment.
Choice C rationale
Continuous use of antipyretics is unnecessary post-treatment. Fever management is more critical during active infection. Post-treatment, fevers should subside, making continuous medication redundant and possibly harmful.
Choice D rationale
Auditory monitoring is crucial after meningitis due to the risk of hearing loss, a common complication. Early detection of auditory issues allows for timely intervention and support for the child’s development.
Correct Answer is C
Explanation
Choice A rationale
Reduction of fever is not the primary goal of albumin therapy. Albumin's role in nephrotic syndrome is to manage severe edema, not to reduce fever, which might be managed by antipyretics if present.
Choice B rationale
Weight gain is typically undesirable in nephrotic syndrome patients due to fluid retention and edema. Albumin therapy aims to reduce edema, potentially decreasing weight as fluid balance improves.
Choice C rationale
Albumin infusion helps reduce edema by increasing plasma oncotic pressure, drawing fluid back into the vascular system. A reduction in edema indicates the therapy’s effectiveness in managing nephrotic syndrome symptoms.
Choice D rationale
Improved caloric intake is not directly affected by albumin infusion. While managing edema might improve overall well-being, albumin’s primary function in this context is fluid balance and reducing swelling.
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