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.

Answer and Explanation

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. .

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Correct Answer is D

Explanation

Choice A rationale

Typing and crossmatching for a possible transfusion is not the immediate priority for a child with hemophilia who has a swollen knee. While a transfusion might be necessary if there is significant bleeding, initial management should focus on controlling the bleeding and minimizing joint damage.

Choice B rationale

Initiating an IV site and beginning infusing normal saline is not the first action to take in this scenario. While IV access might be needed later, immediate measures should focus on controlling bleeding and reducing swelling to prevent further damage to the knee joint.

Choice C rationale

Monitoring the child's vital signs frequently is important, but it is not the first action to take. The priority is to control the bleeding and reduce the swelling, which are the immediate concerns in this situation.

Choice D rationale

Applying an ice pack and compression dressing to the knee is the first action to take. This helps to control bleeding, reduce swelling, and minimize joint damage. This is a crucial step in managing hemophilia-related injuries and should be done immediately upon recognizing a swollen joint.

A. Bleeding tendencies. B. Fluid balance. C. Heat loss. D. Hypoglycemia.

Correct Answer is C

Explanation

Choice A rationale

While bleeding tendencies can be a concern in newborns, especially if there are clotting disorders, it is not the immediate priority in the first minutes after birth. Immediate interventions focus on establishing effective respirations and ensuring adequate oxygenation.

Choice B rationale

Fluid balance is important for newborns, particularly in the context of hydration and potential complications like hypovolemia. However, the most immediate concern after birth is ensuring the newborn can breathe adequately to deliver oxygen to the body's tissues.

Choice C rationale

Heat loss is a critical issue for newborns, as they are at high risk for hypothermia due to their large surface area relative to body weight and limited ability to generate heat. Preventing heat loss helps to stabilize the newborn's temperature and supports overall physiological stability, including respiratory function.

Choice D rationale

Hypoglycemia can be a concern in newborns, particularly those who are small for gestational age or have other risk factors. However, the most immediate concern in the first minutes after birth is ensuring adequate breathing to support oxygenation and prevent complications related to hypoxia. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. Which action should the nurse implement first?

Correct Answer is D

Explanation

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?

Correct Answer is C

Explanation

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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?