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 A
Explanation
Choice A reason: This statement is correct, as hydrostatic reduction of telescoped bowel with an air or saline enema is the preferred treatment for intussusception, which is a condition where a segment of the intestine slides into another segment, causing obstruction, inflammation, and ischemia. The enema can help to push the invaginated bowel back to its normal position, relieve the obstruction, and restore the blood flow. The procedure is safe, effective, and minimally invasive, and can avoid the need for surgery.
Choice B reason: This statement is incorrect, as hydrostatic reduction of telescoped bowel with an air or saline enema is not a false statement, but a true one. The nurse should be aware of the indications, contraindications, and complications of this procedure, and monitor the child's vital signs, abdominal distension, bowel sounds, and stool output before, during, and after the enema. The nurse should also educate the parents about the signs and symptoms of recurrence, such as abdominal pain, vomiting, or bloody stools.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as most infants are ready to start solid foods when they are 4 to 6 months old, depending on their individual growth and readiness. The nurse should explain to the parents that some signs of readiness include being able to hold the head up, sit with support, show interest in food, and move food from the spoon to the throat.
Choice B reason: This statement is incorrect, as 2 to 3 months is too early to introduce solid foods to infants, as their digestive system and swallowing skills are not mature enough to handle them. The nurse should advise the parents to avoid giving solid foods before 4 months of age, as it can increase the risk of choking, allergies, obesity, and iron deficiency.
Choice C reason: This statement is incorrect, as 1 year is too late to introduce solid foods to infants, as they need more nutrients and calories than breast milk or formula alone can provide. The nurse should inform the parents that delaying solid foods beyond 6 months of age can lead to growth faltering, micronutrient deficiencies, and feeding difficulties.
Choice D reason: This statement is incorrect, as 10 to 11 months is too late to introduce solid foods to infants, as they need more nutrients and calories than breast milk or formula alone can provide. The nurse should inform the parents that delaying solid foods beyond 6 months of age can lead to growth faltering, micronutrient deficiencies, and feeding difficulties.
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