The mother of a 3-week-old reports to the nurse that her child cries frequently and seems to always be hungry. She further reports that her child breastfeeds well and has 7 to 8 wet diapers daily. The nurse determines that the child's weight is the same as the birth weight. Which information is most important for the nurse to obtain?
Interest in enrolling in breast feeding classes.
Herbal supplements the mother is taking.
Types of foods the mother is eating.
Length of time the infant nurses at each breast.
The Correct Answer is D
Rationale:
A. Interest in enrolling in breastfeeding classes: While breastfeeding education is helpful, it does not directly address the immediate concern of poor weight gain in the infant.
B. Herbal supplements the mother is taking: Herbal supplements may affect milk production or infant tolerance in some cases, but they are less likely to be the primary factor when the infant is feeding frequently and producing an adequate number of wet diapers.
C. Types of foods the mother is eating: Maternal diet generally does not significantly impact breast milk quantity or quality in healthy, well-nourished women. While important for overall health, it is not the most critical factor to assess here.
D. Length of time the infant nurses at each breast: Assessing how long the infant feeds at each breast provides crucial information about milk transfer and effectiveness of breastfeeding. Despite frequent nursing and normal diaper output, inadequate time at the breast may explain why the infant has not regained birth weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Keep house pets away from the food preparation area: While maintaining hygiene around pets is good practice, rotavirus is primarily transmitted via the fecal-oral route between humans, so pet contact is not a major factor in prevention.
B. Use only lactose-free formulas: Lactose-free formulas address lactose intolerance but do not prevent rotavirus infection. Formula type has no impact on viral transmission.
C. Avoid feeding infants fresh fruits: Fresh fruits are generally safe and do not increase the risk of rotavirus infection if proper hand hygiene and food handling practices are followed. Avoiding fruits is unnecessary.
D. Wash hands before any food preparation: Rotavirus is highly contagious and spreads via the fecal-oral route. Proper handwashing before preparing or feeding food is a key preventive measure to reduce the risk of infection in infants.
Correct Answer is ["A","C","D","E","F"]
Explanation
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.
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