A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in plan of care?
Ensure placement of the enteral tube with an abdominal x-ray.
Speak to the healthcare provider about instituting physical therapy.
Offer a pacifier for non-nutritive sucking.
Use sterile technique during feedings.
The Correct Answer is C
A. Ensure placement of the enteral tube with an abdominal x-ray: Verifying enteral tube placement is essential for safety, but it is not related to maintaining the newborn's growth and development. Tube placement should already have been verified prior to initiating feedings.
B. Speak to the healthcare provider about instituting physical therapy: Physical therapy may be beneficial for infants with specific motor delays, but it is not a routine intervention for all infants recovering from gastroschisis.
C. Offer a pacifier for non-nutritive sucking: Non-nutritive sucking (e.g., using a pacifier) is crucial for the growth and development of newborns, especially those unable to feed orally. It helps promote oral-motor development, soothes the infant, and lays the foundation for transitioning to oral feeding. This is particularly important for an infant receiving parenteral or enteral nutrition to ensure they develop the skills and comfort needed for future oral feeding.
D. Use sterile technique during feedings: Clean technique is generally sufficient or routine enteral feedings unless there is a specific indication for sterility (e.g., immunocompromised clients). Further, this does not directly support growth and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Weight loss can occur in acute glomerulonephritis due to decreased appetite and fluid imbalances, but it is not as immediately concerning as low blood pressure.
B. A positive rapid strep test of the oropharynx suggests streptococcal infection, which can be a cause of acute glomerulonephritis. It's important to report this finding to the healthcare provider, but the low blood pressure is of more immediate concern.
C. Blood pressure 88/50 mm Hg.
Acute glomerulonephritis can lead to various signs and symptoms, including fatigue, facial puffiness, decreased appetite, and dark urine, due to the presence of blood and protein in the urine. However, the drop in blood pressure (88/50 mm Hg) is a significant finding that may suggest potential complications or worsening renal function. Low blood pressure can result from fluid shifts, reduced circulating blood volume, and decreased cardiac output in acute glomerulonephritis. It should be reported to the healthcare provider for further evaluation and management.
D. A maculopapular rash over the trunk of the body is not a typical finding associated with acute glomerulonephritis. While it may be significant for other reasons, it may not be directly related to the child's kidney condition.
Monitoring and addressing blood pressure changes is a crucial aspect of managing acute glomerulonephritis, and the healthcare provider should be informed promptly to assess and address this issue.
Correct Answer is ["B","F","H"]
Explanation
For this client with a history of Wilms tumor, a radical nephrectomy, chronic kidney disease, and ongoing follow-up by oncology and nephrology services, the nurse should prioritize the following three care needs:
B. Identifying cardiac arrhythmias: Given the history of chronic kidney disease and potential electrolyte imbalances, cardiac arrhythmias are a significant concern that should be assessed and monitored for.
F. Monitoring fluid status: Fluid balance is crucial in clients with chronic kidney disease, and monitoring for fluid overload or dehydration is essential. This is especially important because of the potential need for fluid restrictions.
H. Assessing for worsening respiratory status: Assessing respiratory status is important, as clients with chronic kidney disease may be at risk for respiratory complications, including fluid overload, pulmonary edema, or other issues that can impact their respiratory status.
The other options are not the top priorities based on the client's history and current condition:
A. Collaborating with a dietitian to prepare a low-protein diet is important but may not be the immediate priority.
C. Performing diagnostic testing to determine the cause of a fever is necessary, but it does not take precedence over the immediate concerns of cardiac arrhythmias, fluid status, and respiratory status.
D. Educating the client and family on the importance of fluid restrictions is important, but it is related to monitoring fluid status and may be part of ongoing care.
E. Administering antipyretic medication as needed is relevant for fever management but not a top priority until the cause of the fever is determined.
G. Reassessing vital signs is part of ongoing care but may not be the immediate priority over identifying cardiac arrhythmias and assessing for worsening respiratory status.
I. Investigating acid/base complications is important but may not be the immediate priority when cardiac, fluid, and respiratory status are concerns.
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