While caring for a 3-month-old infant, the practical nurse (PN) observes the mother propping the bottle on a pillow to feed the child.
Which should the PN implement?
Encourage the mother not to prop the bottle.
Share the observation with the charge nurse.
Ask the mother if she is too tired to feed her baby.
Observe the infant's behavior during the feeding.
The Correct Answer is A
Choice A rationale
Propping a bottle can lead to several adverse outcomes for an infant. It increases the risk of aspiration, as the infant may not be able to control the milk flow adequately. It can also contribute to otitis media due to milk pooling in the eustachian tubes and is associated with dental caries, particularly bottle mouth syndrome, and impaired bonding.
Choice B rationale
Sharing the observation with the charge nurse without first addressing the issue directly with the mother is not the most immediate or appropriate action. The PN should first attempt to educate and guide the mother, as this is within the scope of practice for direct client care and education.
Choice C rationale
Asking the mother if she is too tired is speculative and may be perceived as judgmental, potentially creating a barrier to effective communication and education. The PN's role is to provide health education and guidance regarding safe infant feeding practices, focusing on the behavior rather than the mother's perceived fatigue.
Choice D rationale
While observing the infant's behavior during feeding is important for a comprehensive assessment, the immediate and most critical action is to intervene with the unsafe practice of bottle propping. Observing further without addressing the identified risk delays necessary education and intervention to ensure infant safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A heart rate of 60 beats/minute for a 9-month-old infant is significantly below the normal physiological range (90-140 beats/minute). Digoxin primarily acts to slow the heart rate and increase contractility, but such a low rate indicates severe bradycardia, a potentially dangerous adverse effect of digoxin toxicity due to excessive parasympathetic stimulation and impaired atrioventricular conduction.
Choice B rationale
A heart rate of 120 beats/minute is within the normal resting range for a 9-month-old infant, which typically falls between 90-140 beats/minute. Digoxin’s therapeutic effect in infants with cardiac conditions often aims to bring the heart rate to a more efficient and less tachycardic rate, thereby improving cardiac output without causing bradycardia.
Choice C rationale
A heart rate of 80 beats/minute is below the typical normal range for a 9-month-old infant (90-140 beats/minute). While digoxin can decrease heart rate, 80 beats/minute suggests an excessive therapeutic effect, potentially indicating mild bradycardia which could compromise cardiac output and tissue perfusion.
Choice D rationale
A heart rate of 180 beats/minute is significantly above the normal physiological range for a 9-month-old infant (90-140 beats/minute). This elevated rate indicates persistent tachycardia, suggesting that the digoxin has not achieved its therapeutic effect of slowing the heart rate, or that the underlying cardiac issue is not adequately controlled.
Correct Answer is C
Explanation
Choice A rationale
While suctioning with a bulb syringe may be indicated for secretions, in an active choking episode with a foreign body obstruction, it is not the immediate first action. Back-blows are more effective at dislodging the obstructing object by increasing intrathoracic pressure and creating an artificial cough.
Choice B rationale
Monitoring respirations for 15 seconds is a delay in critical intervention for an infant actively choking. An infant who is choking requires immediate, active intervention to clear the airway and restore effective breathing, as prolonged airway obstruction can quickly lead to hypoxia and cardiac arrest.
Choice C rationale
In a choking infant, the immediate and most effective first action is to perform three back-blows. This maneuver utilizes gravity and rapid increases in intrathoracic pressure to dislodge the foreign object from the airway, aiming to clear the obstruction quickly and restore ventilation.
Choice D rationale
Stopping the feeding and sitting the infant upright might be appropriate if the infant is merely gagging or coughing, but for active choking, this action alone is insufficient to dislodge an aspirated object. Active intervention like back-blows is required to overcome the obstruction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.