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.
"Avoid vigorous activity, such as bathing, immediately after feeding.”
"Hold the infant in an upright position for 30 minutes after feeding.”
"Enlarge the bottle's nipple opening when using thickened feedings.”
"Prop the bottle during feedings.”
"Feed the infant in a side-lying position.”
The Correct Answer is B
Choice A rationale:
Avoiding vigorous activity immediately after feeding is not directly related to managing gastroesophageal reflux. The rationale behind this is that keeping the infant upright after feeding helps prevent stomach contents from flowing back into the esophagus. Gravity can help reduce reflux symptoms. Vigorous activities do not impact reflux directly.
Choice B rationale:
Holding the infant in an upright position for 30 minutes after feeding is the correct choice. This position utilizes gravity to keep stomach contents down and prevents reflux. It allows time for the food to move from the stomach to the small intestine, reducing the likelihood of reflux. This intervention is widely recommended for infants with gastroesophageal reflux.
Choice C rationale:
Enlarging the bottle's nipple opening when using thickened feedings is not a recommended practice. Thickened feedings can help reduce reflux, but changing the nipple opening size is not necessary for managing reflux symptoms. The thickness of the feeding itself can help prevent regurgitation.
Choice D rationale:
Propping the bottle during feedings is not recommended. It can lead to aspiration, where the milk can enter the infant's airways, causing respiratory issues. It's essential for the infant to be held in an upright position during feedings to prevent reflux symptoms effectively.
Choice E rationale:
Feeding the infant in a side-lying position is not recommended for infants with gastroesophageal reflux. This position can increase the risk of regurgitation and aspiration. Keeping the infant upright, as mentioned in choice B, is the preferred position to minimize reflux symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Lime-flavored ice pops are cold and soothing, which helps reduce throat pain and swelling post-tonsillectomy. They also provide hydration and are less likely to irritate the surgical site compared to dairy products.
Choice B rationale: Sugar-free cherry gelatin, while hydrating and easy to swallow, may not be recommended immediately post-tonsillectomy. The red dye can be confused with blood if the child vomits, making it harder to assess post-surgical complications.
Choice C rationale: Vanilla ice cream contains dairy, which can increase mucus production and cause throat irritation, potentially making it uncomfortable for a child post-tonsillectomy. It's better to avoid dairy products initially to prevent such issues.
Choice D rationale: Chocolate milk, like vanilla ice cream, contains dairy that can increase mucus production. Additionally, the chocolate can be irritating to a healing throat. Cold, clear, non-dairy fluids are preferable initially post-tonsillectomy for comfort and safety.
Correct Answer is B
Explanation
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.
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