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 D
Explanation
Choice A rationale:
An increase in venous pressure is not an indication that furosemide, a loop diuretic, is effective. In fact, increased venous pressure could suggest worsening heart failure. Loop diuretics like furosemide work by promoting the excretion of excess fluid and sodium from the body, leading to a decrease in blood volume and relieving symptoms of heart failure, such as peripheral edema and pulmonary congestion.
Choice B rationale:
A decrease in cardiac output is not the desired effect of furosemide. Furosemide helps reduce fluid overload and congestion in the heart and lungs, ultimately improving cardiac output. If cardiac output decreases, it indicates that the medication might not be effective or the heart failure is worsening.
Choice C rationale:
An increase in potassium levels is not directly related to the effectiveness of furosemide. Furosemide can cause potassium depletion as it increases the excretion of potassium in the urine. Monitoring potassium levels is essential because severe hypokalemia can lead to cardiac arrhythmias. However, the absence of an increase in potassium levels does not indicate furosemide's effectiveness.
Choice D rationale:
A decrease in peripheral edema is the desired effect of furosemide. By reducing fluid retention, furosemide helps decrease peripheral edema, which is a common symptom of heart failure. The nurse should assess the child for a decrease in peripheral edema to determine the medication's effectiveness. Monitoring daily weights and assessing for reduced edema are key indicators of furosemide's efficacy.
Correct Answer is A
Explanation
Choice A rationale:
Bradycardia, or a slow heart rate, is a manifestation of digoxin toxicity. Digoxin, a medication commonly prescribed for heart conditions, can cause toxic effects when its levels become too high in the body. Bradycardia is a result of the drug's action on the heart's electrical conduction system and indicates toxicity.
Choice B rationale:
Diaphoresis, or excessive sweating, is not a specific manifestation of digoxin toxicity. While sweating can occur due to various reasons, it is not a characteristic sign of digoxin toxicity.
Choice C rationale:
Jaundice, or yellowing of the skin and eyes, is not a typical manifestation of digoxin toxicity. Jaundice is more commonly associated with liver or bile duct disorders.
Choice D rationale:
Polyuria, or excessive urination, is not a specific sign of digoxin toxicity. Digoxin toxicity primarily affects the heart and its electrical conduction system, leading to symptoms like bradycardia.
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