The parents of a 28-week gestation neonate ask the nurse, “Why does he have to be fed through a tube in his mouth? What is the nurse’s best response?”
The baby’s sucking, swallowing, and breathing are not coordinated yet.
The baby’s stomach cannot digest formula at this time.
It allows us to accurately determine the baby’s intake since he is so small.
It helps to prevent thrush, an infection that could affect the baby’s mouth.
The Correct Answer is A
Choice A rationale
Preterm infants lack coordination for sucking, swallowing, and breathing until approximately 32-34 weeks' gestation. Gavage feeding prevents aspiration by bypassing the immature oral motor mechanisms required for safe oral feeding.
Choice B rationale
Preterm infants can digest milk due to functional gastrointestinal enzymes. Digestive immaturity relates more to delayed gastric emptying rather than the inability to process nutrients, which is managed with small frequent feeds.
Choice C rationale
Monitoring intake is crucial for growth and hydration, but gavage feeding primarily addresses feeding immaturity, not intake measurement. Accurate intake can be monitored through oral feeds with supplemental measurements.
Choice D rationale
Gavage feeding does not directly prevent thrush. Thrush prevention involves oral hygiene and immune support rather than feeding methods, as thrush may still occur regardless of tube feeding or oral intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Manually removing the placenta can introduce infection and cause uterine injury, which are not preventive measures for postpartum hemorrhage but treatments for retained placenta requiring sterile conditions and medical indication.
Choice B rationale
Administering antibiotics does not directly prevent postpartum hemorrhage, as it focuses on managing infections like endometritis. Hemorrhage prevention is better addressed by uterine tone management and avoiding excessive bleeding.
Choice C rationale
Applying pressure to the umbilical cord can lead to uterine inversion, worsening hemorrhage. Controlled cord traction during active management of the third stage is safer and reduces hemorrhage risk effectively.
Choice D rationale
Frequent urination prevents bladder distension, which enhances uterine contraction. A contracted uterus reduces hemorrhage risk by compressing blood vessels. Distended bladder inhibits proper uterine contraction, increasing hemorrhage likelihood.
Correct Answer is B
Explanation
Choice A rationale
A pulse rate of 80 and regular does not directly indicate Methergine's effectiveness. Normal pulse ranges from 60 to 100 beats per minute. This could result from overall stabilization rather than medication effect.
Choice B rationale
A firm uterine fundus at the umbilicus and moderate lochia indicate effective uterine contraction and hemostasis, reflecting successful intervention with Methergine in managing postpartum hemorrhage.
Choice C rationale
A blood pressure of 120/80 is within the normal adult range but does not specifically reflect Methergine's uterotonic action. Blood pressure monitoring is essential but not the primary efficacy indicator.
Choice D rationale
An increase in prothrombin time reflects coagulation changes but is unrelated to Methergine's mechanism of action. It focuses on hemostatic effects via uterine contractions rather than coagulation pathways.
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