The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care should include which of the following?
Elevating the head but give nothing by mouth
Elevating the head for feedings
Avoiding suction unless infant is cyanotic
Feeding glucose water only
The Correct Answer is A
When caring for a neonate with a suspected tracheoesophageal fistula (TEF), nursing care should include elevating the head but giving nothing by mouth. Tracheoesophageal fistula is a condition where an abnormal connection exists between the trachea and oesophagus, leading to the passage of air and secretions between these structures. Feeding the infant orally can result in aspiration of feedings into the lungs, which can cause respiratory distress and complications. Therefore, it is important to keep the neonate in an upright position to reduce the risk of aspiration until a definitive diagnosis and treatment plan are established.
elevating the head for feedings in (option B), is not appropriate in this case as oral feedings should be avoided until the tracheoesophageal fistula is addressed.
avoiding suction unless the infant is cyanotic in (option C), is not correct. Suctioning may be necessary in neonates with suspected tracheoesophageal fistula to clear secretions and maintain a patent airway.
feeding glucose water only in (option D), is not an appropriate intervention for a neonate with a suspected tracheoesophageal fistula. In this situation, all oral feedings should be withheld until further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The most appropriate statement by the nurse to a 15-year-old whose friend has mentioned suicide is option A. The statement acknowledges the seriousness of the situation and emphasizes the importance of taking the friend's threat seriously. It also highlights the need for immediate help and intervention. Suicide threats should never be dismissed or taken lightly, and it is crucial to involve professionals who can provide appropriate support and assistance.
"Tell your friend to come to the clinic immediately," in option B is incorrect because places the responsibility solely on the 15-year-old to relay the message to their friend, which may not be the most effective or timely approach.
"If your friend mentions suicide again, get your friend some help," in (option C) is incorrect because it does not address the urgency of the situation. Waiting for the friend to mention suicide again before acting may lead to potential harm.
"You need to gather details about your friend's suicide plan," is incorrect because places the responsibility on the 15-year-old to gather information about the friend's suicidal intentions. While understanding the situation and obtaining relevant details is important, the immediate priority is ensuring the friend's safety and seeking professional help.
Correct Answer is B
Explanation
The statement that best describes why infants are at greater risk for dehydration than older children is option B. Infants have an increased extracellular fluid volume compared to older children. This means that a larger proportion of their total body fluid is located outside the cells, in the extracellular compartment. This higher extracellular fluid volume makes infants more susceptible to fluid losses and dehydration if they experience inadequate fluid intake or increased fluid losses.
infants have an increased ability to concentrate urine in (option A), is incorrect. Infants have limited renal function and may have difficulty concentrating urine compared to older children and adults. This can contribute to a higher risk of dehydration in infants.
infants have a greater volume of intracellular fluid in (option C), is incorrect. The volume of intracellular fluid is not the primary factor contributing to the increased risk of dehydration in infants.
infants have a smaller body surface area in (option D) is incorrect because it, is not directly related to the increased risk of dehydration. Body surface area influences heat exchange and fluid loss through sweating but is not the main factor contributing to the higher risk of dehydration in infants.
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