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Patient Data

Exhibits
The nurse has mixed the formula with enteral nutritional formula powder to increase the caloric content to 24 calories per ounce (24 cal/30 mL).Which nursing intervention(s) should the nurse include from the plan of care to help meet the client's nutritional needs? Select all that apply.

Slowly increase caloric content using enteral nutritional formula powder.

Feed the infant on demand.

Make sure the infant is well rested before feeds.

Wake the infant up to eat.

Stroke the cheek to encourage sucking.

Initiate a three-hour feeding schedule.

Feed for one-hour duration.

Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube.

Answer and Explanation

Correct Answer : A,C,D,E,F

Rationale:

A. Slowly increase caloric content using enteral nutritional formula powder: Gradually increasing caloric density helps meet the infant’s energy requirements without overloading the gastrointestinal system, which is crucial for infants with heart failure and fatigue during feeds.

B. Feed the infant on demand: These infants are at high risk for fatigue, and feeding requires a significant amount of energy. This can lead to decreased intake and further weight loss. A structured feeding schedule is more appropriate to ensure adequate caloric intake.

C. Make sure the infant is well rested before feeds: Ensuring the infant is rested prior to feeding reduces fatigue, improves endurance, and increases the likelihood of adequate intake.

D. Wake the infant up to eat: Infants with heart failure and failure to thrive may not wake spontaneously for feeds; waking them ensures they receive adequate nutrition for growth and energy.

E. Stroke the cheek to encourage sucking: Tactile stimulation can promote sucking reflexes and help the infant feed more effectively, which is particularly important in fatigued infants.

F. Initiate a three-hour feeding schedule: Infants with heart failure fatigue easily. A structured feeding schedule, such as every 3 hours, is critical to ensure the infant receives consistent nutrition and hydration. This approach prevents the infant from becoming too hungry and ensures that feeding sessions are spaced out enough for the infant to rest and recover.

G. Feed for one-hour duration: Prolonged feeding times are not recommended for infants with fatigue; feeds should be effective but brief to prevent exhaustion.

H. Give gavage feedings via percutaneous endoscopic gastrostomy (PEG) tube: PEG tube feedings are not indicated at this time since the infant is able to feed orally with support and stimulation.

Nursing Test Bank

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Correct Answer is ["A","B","D","F"]

Explanation

Rationale:

A. Does the toddler experience choking or gagging after eating?: Asking about choking or gagging helps identify possible swallowing difficulties or risk of aspiration, which may complicate upper respiratory infections.

B. Has the toddler been treated for these symptoms before?: Knowing prior treatments or recurrent infections provides context for chronicity, helps identify resistant infections, and guides current care decisions.

C. Does the toddler follow a strict daily routine?: While routines affect behavior and sleep, this information is not directly relevant to assessing the current respiratory illness or risk factors.

D. Does the toddler attend daycare?: Attendance at daycare increases exposure to infectious agents and helps evaluate risk for contagious illness or recurrent upper respiratory infections.

E. Does the toddler eat table food?: Diet details are not immediately relevant to the acute assessment of respiratory symptoms and infection risk.

F. Does smoking occur in the home?: Exposure to secondhand smoke increases the risk of respiratory infections and may exacerbate symptoms, making it an important factor in assessment.

A. Obtain a urine specimen and determine blood type. B. Palpate the fundus and check the fetal heart rate. C. Complete a vaginal exam and test for ruptured membranes. D. Start IV fluid bolus and obtain a complete blood count.

Correct Answer is B

Explanation

Rationale:

A. Obtain a urine specimen and determine blood type: While obtaining a urine specimen and knowing the blood type are important for baseline assessment, these actions do not immediately address the acute maternal and fetal risks associated with third-trimester bleeding.

B. Palpate the fundus and check the fetal heart rate: Assessing the uterine fundus and fetal heart rate is the highest priority because it provides critical information about maternal bleeding, uterine tone, and fetal well-being. These assessments help determine if the client is experiencing placental abruption or another emergent complication.

C. Complete a vaginal exam and test for ruptured membranes: A vaginal exam is contraindicated in cases of unknown third-trimester bleeding until placental location is confirmed, as it may worsen bleeding.

D. Start IV fluid bolus and obtain a complete blood count: Administering IV fluids and obtaining labs are necessary for stabilizing the client and assessing blood loss, but these interventions follow immediate assessment of maternal and fetal status.

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Nursing Test Bank

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Patient Data Exhibits The healthcare provider initiates prescriptions. Select the additional 4 questions the nurse should include in the assessment.

Correct Answer is ["A","B","D","F"]

Explanation

A client in her third trimester reports abdominal pain. She is restless and has a small amount of dark red vaginal bleeding. Which actions should the nurse implement first?

Correct Answer is B

Explanation

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