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 B
Explanation
Choice A reason: This is not a good choice. IV fluid bolus of 10 ml/kg is not enough to restore the circulating volume and perfusion in a child with hypovolemic shock. The recommended initial fluid bolus for pediatric hypovolemic shock is 20 ml/kg of isotonic crystalloid solution.
Choice B reason: This is the correct choice. Oxygen, IV fluid bolus of 20 ml/kg, and medications to support cardiac function are the appropriate interventions for a child with hypovolemic shock. Oxygen is given to improve oxygenation and prevent tissue hypoxia. IV fluid bolus of 20 ml/kg is given to replace the lost fluid and blood volume and improve the blood pressure and cardiac output. Medications to support cardiac function may include inotropes, vasopressors, or antiarrhythmics, depending on the child's condition and the cause of the shock.
Choice C reason: This is not a good choice. IV at 2x maintenance is not sufficient to correct the hypovolemia and shock in a child. Maintenance fluids are given to prevent dehydration and electrolyte imbalance, but they are not enough to restore the hemodynamic stability and perfusion in a child with shock. A fluid bolus is needed to rapidly increase the intravascular volume and improve the vital signs.
Choice D reason: This is not a good choice. Oxygen and medication to support cardiac function are important, but they are not enough to reverse the hypovolemic shock in a child. A fluid bolus is the first and most essential intervention to correct the hypovolemia and shock in a child. Giving medication before fluid bolus may worsen the shock and cause adverse effects.
Correct Answer is A
Explanation
Choice A reason: The squeeze bottle and ESSR method of feeding are recommended for infants with cleft lip and palate as they allow for better control of the flow and volume of the formula, prevent air swallowing and aspiration, and promote oral stimulation and development.
Choice B reason: Supplemental feeding through an N/G tube is not usually necessary for infants with cleft lip and palate unless they have severe feeding difficulties, failure to thrive, or other complications. The goal is to promote oral feeding as much as possible.
Choice C reason: Adding rice cereal to the formula is not advised for infants with cleft lip and palate as it can increase the risk of aspiration, choking, and infection. Rice cereal can also interfere with the absorption of iron and other nutrients from the formula.
Choice D reason: Infants with cleft lip and palate usually have a hard time breastfeeding as they cannot create a proper seal and suction with the nipple. Breastfeeding may be possible with some modifications and support, but it is not the norm.
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