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 C
Explanation
When caring for a school-age child immediately following a tonsillectomy in the Post-Anesthesia Care Unit (PACU), the nurse should prioritize actions that promote the child's comfort and recovery while minimizing the risk of complications. The most appropriate action is:
c) Offer the child ice cream when alert.
After a tonsillectomy, cold and soothing foods like ice cream can help alleviate throat pain and reduce swelling. However, it's crucial to wait until the child is fully alert and able to swallow safely. Ice cream provides a cool and gentle way to soothe the surgical site.
The other options may not be suitable immediately following a tonsillectomy:
a) Placing the child in a side-lying position: While positioning can be essential for airway management, it's not a specific intervention related to a tonsillectomy in the immediate postoperative period.
b) Instructing the child to drink fluids through a straw: Drinking through a straw may increase the risk of bleeding, which is a concern after a tonsillectomy. It's often recommended to avoid straws initially.
d) Encouraging the child to deep breathe and cough: While respiratory care is generally important, the immediate focus after a tonsillectomy is on maintaining a clear airway and managing pain. Deep breathing and coughing exercises may be introduced later in the recovery process.
It's important for the nurse to follow the specific postoperative guidelines provided by the surgical team and be attentive to the child's individual needs and responses.
Correct Answer is B
Explanation
Choice A rationale:
Limb withdrawal is a pain response and indicates that the infant is experiencing pain. The goal of opioid pain medication is to alleviate pain, so limb withdrawal suggests inadequate pain control.
Choice B rationale:
A relaxed facial expression indicates that the infant is comfortable and not experiencing pain. It is a positive sign that the medication is having a therapeutic effect by providing pain relief.
Choice C rationale:
Increased blood pressure is not a typical response to opioid pain medication. Opioids often cause a decrease in blood pressure and can lead to hypotension.
Choice D rationale:
Bradycardia (slow heart rate) is not a common response to opioid pain medication. Opioids can cause respiratory depression and bradypnea (slow breathing), but they do not typically cause bradycardia.
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