A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.

Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.

Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.

Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.

Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).

The correct answer is choice a. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to decreased glucose availability for the fetus, which can result in fetal bradycardia due to reduced energy supply.

Choice B rationale:

Fetal anemia typically causes fetal tachycardia rather than bradycardia, as the fetus compensates for the lack of oxygen-carrying capacity by increasing the heart rate.

Choice C rationale:

Chorioamnionitis, an infection of the fetal membranes, usually causes fetal tachycardia due to the inflammatory response and fever.

Choice D rationale:

Maternal fever is more likely to cause fetal tachycardia rather than bradycardia, as the increased maternal temperature can lead to an increased fetal heart rate.