The nurse has reviewed the Nurses' Notes at 1010.
Exhibit 1. Nurses' Notes.
Today, 1000: Exhibit 2. Infant here at the provider's office for a scheduled visit.
The infant is in their parent's arms, grimacing.
Exhibit 3. S1 and S2 auscultated, no murmur noted.
Respirations are symmetric and unlabored with abdominal movement.
Abdomen is soft and flat, bowel sounds present.
Current weight is 4.1 kg (9 lb) The parent states they have exclusively breast- and bottle-fed breastmilk to the infant since birth.
The parent states the infant sometimes chokes with bottle feedings.
The parent noticed that the infant recently started "spitting up" during the night and after feeds, and cries excessively.
They state the infant has been vomiting more forcefully and has become disinterested in feeding.
Today, 1010: Provider assessed infant and discussed gastroesophageal reflux with parent.
Education provided.
Select the 3 statements the nurse should include in the teaching.

Choice A rationale:

Feeding the infant a specific volume of formula is not the priority when caring for a child with a cleft of the soft palate. Infants with cleft palate may have difficulty creating suction during feeding, which can lead to inefficient feeding and inadequate intake. It is essential to focus on proper feeding techniques rather than a specific volume.

Choice B rationale:

Elevating the infant's head to a 10° angle during feedings is the correct action. This positioning helps prevent formula or breast milk from flowing into the nasal cavity, reducing the risk of aspiration. Aspiration can lead to respiratory issues and other complications. Elevating the head facilitates swallowing and reduces the risk of choking.

Choice C rationale:

Discontinuing a feeding if the infant's eyes become watery is not a valid indication to stop feeding. Watery eyes are not directly related to feeding difficulties in infants with a cleft palate. It is essential to assess the infant's overall feeding performance and address specific issues such as inadequate suction or swallowing difficulties.

Choice D rationale:

Postponing burping until after completing each feeding is not appropriate. Burping should be done periodically during feedings to prevent the accumulation of air in the infant's stomach, which can cause discomfort and contribute to reflux. Burping helps release trapped air and promotes comfortable feeding experiences for the infant.

Choice A rationale:

Increased respiratory rate is an expected finding in a severely dehydrated infant. Dehydration can lead to an increased breathing rate as the body tries to compensate for reduced blood volume and oxygenation. Respiratory rate may be rapid, and the infant may appear tachypneic. This compensatory mechanism helps maintain oxygen levels in the body.

Choice B rationale:

Capillary refill of 2 seconds is within the normal range and is not indicative of severe dehydration. Prolonged capillary refill time (>2 seconds) can be a sign of poor perfusion and dehydration, but a capillary refill time of 2 seconds is normal.

Choice C rationale:

Increased urine output is not an expected finding in severe dehydration. Dehydration leads to reduced urine output as the body tries to conserve fluids. In a dehydrated infant, urine output may be significantly decreased, indicating a lack of fluid intake and reduced renal perfusion.

Choice D rationale:

Hypertension is not a typical finding in severe dehydration. Dehydration often leads to decreased blood volume, which can result in low blood pressure rather than hypertension. Hypotension, not hypertension, is a common clinical manifestation of severe dehydration.