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: Slowing the heart rate does not increase diastolic filling time. Diastolic filling time is the time during which the ventricles are relaxed and filling with blood. Slowing the heart rate would decrease the cardiac output and worsen the heart failure.
Choice B reason: Increasing urine output does decrease pulmonary congestion, but it is not the primary effect of Captopril. Captopril is an angiotensin-converting enzyme (ACE) inhibitor, which blocks the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This reduces the blood pressure and the afterload on the heart. Diuretics are the drugs that increase urine output and reduce fluid overload.
Choice C reason: This is the correct choice. Decreasing the afterload means reducing the resistance that the heart has to overcome to pump blood to the body. This lowers the blood pressure and the workload on the heart, which improves the cardiac function and reduces the symptoms of heart failure.
Choice D reason: Increasing serum potassium does not improve cardiac performance. In fact, high levels of potassium can cause cardiac arrhythmias and cardiac arrest. Captopril can cause hyperkalemia (high potassium) as a side effect, which is why patients on this drug need to monitor their potassium levels and avoid potassium supplements or salt substitutes.
Correct Answer is A
Explanation
Choice A reason: Using a night-light can provide a sense of security and comfort for a child, especially if they are afraid of the dark. This can help prevent sleep problems by reducing fear and anxiety at bedtime¹.
Choice B reason: While it's true that certain foods can promote sleep, high-carbohydrate snacks before bedtime are not recommended. They can lead to energy spikes and crashes, which can disrupt sleep¹.
Choice C reason: While it's important for the sleep environment to be calming and conducive to sleep, it doesn't always have to be completely quiet and dark. Some children may find a completely dark room scary, and some background noise can actually be soothing¹.
Choice D reason: The need for naps varies greatly among children. Some 4-year-olds may still benefit from an afternoon nap. Eliminating the nap can lead to overtiredness, which can actually make it harder for the child to fall asleep at night¹.
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