A six-week-old infant is one day post-op for a pyloromyotomy for pyloric stenosis. The infant is started on the first oral feedings. Which of the following actions by the mother would most indicate a need for further nursing interventions?
The mother plans to burp the infant after feeding.
The mother plans to give five milliliters of water.
The mother plans to wrap the infant during feeding.
The mother plans to give thirty milliliters of water.
The Correct Answer is D
Choice A reason: This statement is incorrect, as burping the infant after feeding is not a nursing intervention, but a normal practice to prevent gas and discomfort. The nurse should encourage the mother to burp the infant gently after each feeding, and to avoid overfeeding or underfeeding the infant.
Choice B reason: This statement is incorrect, as giving five milliliters of water is not a nursing intervention, but a harmless amount of fluid for the infant. The nurse should inform the mother that water is not necessary for the infant, as breast milk or formula provides enough hydration and nutrition. However, the nurse should also reassure the mother that a small amount of water will not harm the infant.
Choice C reason: This statement is incorrect, as wrapping the infant during feeding is not a nursing intervention, but a comforting measure for the infant. The nurse should support the mother's bonding with the infant, and suggest ways to make the feeding experience more pleasant and relaxing for both of them. The nurse should also monitor the infant's temperature and avoid overheating.
Choice D reason: This statement is correct, as giving thirty milliliters of water is a nursing intervention that indicates a need for further education and guidance. The nurse should explain to the mother that giving too much water to the infant can cause water intoxication, which can lead to hyponatremia, seizures, or even death. The nurse should also teach the mother the signs and symptoms of water intoxication, such as irritability, lethargy, vomiting, or swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false, as a sense of hopelessness and despair are not a normal part of adolescence, but signs of depression and suicidal ideation. The nurse should educate the adolescents and their parents about the warning signs of suicide and the importance of seeking professional help.
Choice B reason: This statement is false, as previous suicide attempts are a major risk factor for completed suicides. The nurse should assess the adolescents for any history of self-harm or suicide attempts and provide them with appropriate interventions and referrals.
Choice C reason: This statement is true, as LGBT adolescents are at a particularly high risk for suicide due to the stigma, discrimination, and bullying they may face from their peers, family, and society. The nurse should provide a safe and supportive environment for the LGBT adolescents and connect them with resources and support groups.
Choice D reason: This statement is false, as problem-solving skills are of great value to the suicidal adolescent. The nurse should teach the adolescents how to cope with stress, deal with conflicts, and seek help when needed. The nurse should also help the adolescents develop positive self-esteem and resilience.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because breastmilk does contain some iron, although not as much as formula. However, the iron in breastmilk is more bioavailable and easily absorbed by the infant. Therefore, iron drops are not necessary for exclusively breast-fed infants until they are 4 to 6 months old.
Choice B reason: This is incorrect because the iron levels of breast-fed infants will start to decline after 4 to 6 months of age, as their iron stores from the mother are used up. Therefore, they will need iron supplementation from other sources, such as iron-fortified cereals or drops.
Choice C reason: This is correct because the iron stores of breast-fed infants are sufficient for the first 4 to 6 months of life, but then they will need additional iron from other sources. Iron supplementation can prevent or treat iron deficiency anemia, which can affect the infant's growth and development.
Choice D reason: This is incorrect because solids are not recommended for infants younger than 4 months of age, as their digestive system is not mature enough to handle them. Solids can also interfere with the intake of breastmilk, which is the main source of nutrition for infants. Iron-rich foods can be introduced after 6 months of age, along with continued breast-feeding.
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