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.
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Related Questions
Correct Answer is A
Explanation
A change in status that should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury is confusion and altered mental status. As intracranial pressure increases, it can affect brain function and lead to neurological changes, including confusion, disorientation, irritability, decreased level of consciousness, or other alterations in mental status. These changes indicate that the brain is being compressed and compromised, and immediate intervention is required.
Option B, increased diastolic pressure with narrowing pulse pressure in (option B) is incorrect because it, can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or systemic conditions. It is important to consider the overall hemodynamic status of the child and assess for additional signs and symptoms of increased ICP.
irregular, rapid heart rate in (option C), can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or other medical conditions. Assessment of heart rate should be considered along with other signs and symptoms of increased ICP.
rapid, shallow breathing, in (option D) can be a sign of increased ICP, but it is not specific to head injuries and can be influenced by other factors such as pain, anxiety, or respiratory conditions. Respiratory assessment should be considered along with other signs and symptoms of increased ICP.
Correct Answer is D
Explanation
When the skin surface is caked with desquamated skin and sebaceous secretions after the removal of a cast, the nurse should suggest washing the area with warm water and soap. This will help to gently cleanse the skin and remove the accumulated material without causing unnecessary trauma or irritation.
Option A, applying powder to absorb the material, may not effectively remove the caked material and could potentially lead to further clumping or discomfort.
Option B, vigorously scrubbing the leg, can be harsh on the skin and may cause skin irritation, redness, or even abrasions. It is important to be gentle and avoid excessive scrubbing, especially on the fragile and recently exposed skin.
Option C, carefully picking the material off the leg, can increase the risk of skin injury or introduce bacteria into the skin. Picking at the skin should be avoided to prevent further damage or infection.
Therefore, option D, washing the area with warm water and soap, is the most appropriate and gentle method to remove the caked material from the skin surface
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