During a routine clinic visit, a nurse finds that a 5-year-old girl’s systolic blood pressure is above the 90th percentile. What should be the nurse’s subsequent action?

= Answer is... Choice B. Offer a pacifier for non-nutritive sucking.

Choice A rationale:

In the context of a newborn with a repaired gastroschisis receiving parenteral nutrition and continuous enteral feedings, instituting physical therapy may not directly contribute to the maintenance of normal growth and development concerning nutrition. While physical therapy plays a vital role in promoting motor development and rehabilitation in infants with various medical conditions, its immediate relevance to nutritional support in this scenario may be limited. Instead, the focus of care for this infant revolves around optimizing nutritional intake and supporting oral feeding skills, making physical therapy a less prioritized intervention at this stage.

Choice B rationale:

Offering a pacifier for non-nutritive sucking is a crucial action to include in the plan of care for a newborn receiving enteral nutrition, especially in the context of gastroschisis repair. Non-nutritive sucking serves several purposes beneficial for the infant's development and well-being. Firstly, it promotes the development of oral feeding skills, including suck-swallow coordination and oral motor strength, which are essential for transitioning to oral feeding and achieving nutritional milestones. Secondly, non-nutritive sucking provides comfort and helps infants self-regulate, contributing to their overall physiological and emotional stability. By offering a pacifier for non-nutritive sucking, the nurse supports the infant's oral motor development and enhances their ability to transition from enteral to oral feeding, ultimately promoting normal growth and development.

Choice C rationale:

Ensuring the placement of the enteral tube with an abdominal x-ray is an essential aspect of enteral nutrition administration; however, it may not directly contribute to the maintenance of normal growth and development in the same way as offering a pacifier for non-nutritive sucking does. While verifying enteral tube placement is crucial for preventing complications such as aspiration or malabsorption, continuous reliance on abdominal x-rays for tube placement confirmation poses risks associated with radiation exposure, especially in neonates. Therefore, while verifying tube placement is necessary, it should be balanced with the consideration of minimizing radiation exposure and utilizing alternative methods such as auscultation or pH testing when appropriate.

Choice D rationale:

Using sterile technique during feedings is a fundamental aspect of enteral nutrition administration to minimize the risk of infection and ensure patient safety. However, while maintaining sterility is essential, it may not directly address the specific goal of maintaining normal growth and development in the context of enteral nutrition. The question specifically emphasizes actions to support normal growth and development, which are more directly facilitated by interventions such as non-nutritive sucking to enhance oral feeding skills and self-regulation.

Choice A rationale
Sodium levels are not typically affected by hypoparathyroidism. Hypoparathyroidism primarily affects calcium and phosphorus levels in the body.
Choice B rationale
Hypoparathyroidism leads to abnormally low levels of parathyroid hormone, which results in low calcium levels in the blood. A carpal spasm when pressure is applied to the upper arm, also known as Trousseau’s sign, is a common symptom of hypocalcemia.
Choice C rationale
Potassium levels are not typically affected by hypoparathyroidism. Hypoparathyroidism primarily affects calcium and phosphorus levels in the body.
Choice D rationale
Chloride levels are not typically affected by hypoparathyroidism. Hypoparathyroidism primarily affects calcium and phosphorus levels in the body.