The nurse is providing teaching for the mother of an infant who receives all of his nutrition through a nasogastric feeding tube. The nurse is reviewing interventions to promote growth and development. Which response from the mother indicates a need for further teaching?
"I will give him a pacifier during feeding time."
"We need to make sure he doesn't lose the desire to eat by mouth."
"We need to keep feeding time very quiet."
"Sucking produces saliva, which aids in digestion."
The Correct Answer is A
A. "I will give him a pacifier during feeding time.": Giving a pacifier during feeding time may interfere with the infant's ability to coordinate sucking, swallowing, and breathing, especially if
they are receiving nutrition through a nasogastric tube. This response indicates a need for further teaching because pacifiers during feeding time could potentially disrupt the infant's feeding
pattern and may not be appropriate in this situation.
B. "We need to make sure he doesn't lose the desire to eat by mouth.": This response
demonstrates an understanding of the importance of maintaining the infant's oral feeding skills and indicates appropriate knowledge about promoting oral feeding while using a nasogastric
tube.
C. "We need to keep feeding time very quiet.": Keeping feeding time quiet can help reduce distractions and promote a calm environment, which may enhance feeding tolerance for the infant. This response reflects an understanding of strategies to facilitate feeding.
D. "Sucking produces saliva, which aids in digestion.": This response demonstrates knowledge about the benefits of sucking and saliva production during feeding, indicating an understanding of the infant's physiological needs during feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vary the child's schedule each day: While some variation in activities may be beneficial, providing a stable and predictable routine can also promote a sense of security and stability for the child during hospitalization.
B. According to Erikson's psychosocial development theory, the psychosocial stage for a 10- year-old child is industry versus inferiority. During this stage, children are developing a sense of competence by mastering new skills and tasks. Encouraging the child to complete school work supports this developmental stage by fostering a sense of accomplishment and competence. It
also helps maintain a sense of normalcy and continuity with academic activities despite the hospitalization.
C. Discourage visits from the client's friends: Social interaction with peers is important for the child's emotional well-being and development. Discouraging visits from friends would likely have a negative impact on the child's psychosocial needs during hospitalization.
D. Provide a daily session with a play therapist: While play therapy may be beneficial for addressing emotional needs, it may not directly address the child's psychosocial development according to Erikson's theory. Encouraging completion of school work aligns more closely with the developmental tasks of this stage.
Correct Answer is A
Explanation
A. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.
B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of
dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.
C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.
D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.
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