Which of the following information should a nurse include in the teaching to the parent of a 1-day-old newborn with a prescription for gavage feeding?
Administer 20 mL per feeding.
Feedings should be accompanied by nonnutritive sucking.
Place the newborn in a supine position after feedings.
Feedings may occur in clusters.
The Correct Answer is B
Choice A reason: Administering 20 mL per feeding is not universally appropriate, as gavage feeding volumes depend on the newborn’s weight, gestational age, and medical condition. Standardized volumes risk over- or underfeeding, potentially causing gastric distress or inadequate nutrition. Neonatal physiology requires individualized feeding plans to support digestion and growth, guided by medical prescriptions and clinical assessment.
Choice B reason: Nonnutritive sucking, such as on a pacifier, supports neurological development and soothes newborns during gavage feeding. It stimulates the suck-swallow reflex, enhancing gastrointestinal motility and reducing feeding intolerance. Scientifically, this practice promotes oral motor skills, aiding transition to oral feeding, and provides comfort, which is critical for neonatal stress reduction and developmental progress.
Choice C reason: Placing a newborn in a supine position after gavage feeding increases the risk of aspiration, as milk may reflux into the airway. Neonatal physiology favors a side-lying or prone position to facilitate gastric emptying and reduce regurgitation. This position supports safer digestion and minimizes respiratory complications, aligning with evidence-based neonatal care practices for gavage-fed infants.
Choice D reason: Cluster feedings mimic natural breastfeeding patterns, supporting neonatal nutritional needs and growth. Newborns often feed in clusters to meet caloric demands, stabilize blood glucose, and promote weight gain. This practice aligns with neonatal physiology, as the stomach’s small capacity benefits from frequent, smaller feedings, enhancing digestion and nutrient absorption in gavage-fed infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Rho(D) immune globulin is administered after a miscarriage in Rh-negative women to prevent isoimmunization, as fetal blood mixing can occur. This immunoglobulin neutralizes Rh-positive fetal antigens, preventing maternal antibody formation that could affect future pregnancies. The immune response could otherwise lead to hemolytic disease in subsequent Rh-positive fetuses.
Choice B reason: Administering Rho(D) immune globulin at 12 weeks is not standard practice. It is typically given at 28 weeks and post-delivery or after events like miscarriage. Early administration is unnecessary unless a sensitizing event occurs, as maternal-fetal blood mixing is rare before the third trimester, per immunological principles.
Choice C reason: Rho(D) immune globulin does not prevent preterm labor, which is driven by uterine or hormonal factors. The injection targets Rh isoimmunization by neutralizing Rh-positive fetal antigens. Preterm labor involves prostaglandin and oxytocin pathways, unrelated to Rh sensitization, making this statement irrelevant to the immunoglobulin’s immunological mechanism.
Choice D reason: Rho(D) immune globulin is unnecessary post-delivery if the baby is Rh-negative, as no sensitization occurs without Rh-positive fetal blood. The injection is given only if the baby is Rh-positive to prevent maternal antibody formation. This statement reflects a misunderstanding of Rh immunology and isoimmunization risk in pregnancy.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Acrocyanosis, a benign bluish discoloration of extremities, is common in healthy newborns due to immature peripheral circulation, not specific to neonatal abstinence syndrome (NAS). NAS involves central nervous system irritability from opioid withdrawal, causing symptoms like tachypnea or tremors, not peripheral vasoconstriction unrelated to withdrawal physiology.
Choice B reason: Hypotonia is not typical in neonatal abstinence syndrome, which causes hypertonia due to central nervous system irritability from opioid withdrawal. Hypotonia suggests other conditions, like neuromuscular disorders, not the hyperactive neurological state of NAS, where increased muscle tone and reflexes dominate due to autonomic dysregulation.
Choice C reason: Tachypnea is expected in neonatal abstinence syndrome, as opioid withdrawal causes autonomic hyperactivity, increasing respiratory drive. The newborn’s immature nervous system responds to withdrawal stress with rapid breathing, reflecting heightened metabolic demand and sympathetic activation, a hallmark of NAS requiring careful monitoring to prevent respiratory distress.
Choice D reason: A shrill pitched cry is a classic finding in neonatal abstinence syndrome, indicating central nervous system irritability from opioid withdrawal. The high-pitched cry reflects neurological overstimulation, as the infant’s brain struggles to regulate without opioid exposure, distinguishing NAS from normal newborn behavior and requiring supportive care.
Choice E reason: An exaggerated Moro reflex is expected in neonatal abstinence syndrome, as withdrawal heightens neurological excitability. The reflex, triggered by sudden movement, is amplified due to central nervous system irritability, reflecting the infant’s hypersensitive autonomic response to opioid withdrawal, necessitating calming interventions to reduce overstimulation.
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