A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

A history of gastroesophageal reflux disease.

A residual of 65 mL. 1 hr postprandial.

Sitting in high-Fowler's position during the feeding

Receiving a high-osmolarity formula.

Answer and Explanation

The Correct Answer is A

A. A history of gastroesophageal reflux disease: This factor places the client at a higher risk for aspiration. Patients with gastroesophageal reflux disease (GERD) may experience backflow of stomach contents, which can lead to aspiration, especially when receiving enteral feedings.

B. A residual of 65 mL, 1 hr postprandial: While monitoring residual volumes is important to assess tolerance to feeding, a residual of 65 mL alone does not inherently indicate a high risk for aspiration. It may suggest that the feeding rate needs adjustment but isn't a direct risk factor.

C. Sitting in high-Fowler's position during the feeding: This position is actually protective against aspiration, as it promotes better gastric emptying and reduces the likelihood of reflux.

D. Receiving a high-osmolarity formula: While high-osmolarity formulas can sometimes lead to gastrointestinal discomfort or diarrhea, they do not directly increase the risk of aspiration. Proper management of feeding administration is key.

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Correct Answer is A

Explanation

A. "Ensure the child's hair is clean and without conditioner before the procedure.": This is important because any oils or products in the hair can interfere with the electrodes' ability to detect brain activity accurately. Clean, product-free hair helps ensure the best results from the EEG.

B. "Give the child acetaminophen for pain following the procedure.": EEGs are generally non-invasive and do not typically cause pain, so administering pain relief afterward is usually unnecessary unless specified by a healthcare provider.

C. "Make the child NPO before the procedure.": Typically, there is no need for the child to be NPO (nothing by mouth) for an EEG unless it is specified for a particular type of EEG that might involve sedation. Most routine EEGs do not require this.

D. "Keep the child out of the sun for 4 hr following the procedure.": There are no standard recommendations related to sun exposure after an EEG. Therefore, this instruction is not applicable.

A. Swaddle the newborn with his legs extended, B. Maintain eye contact with the newborn during feedings. C. Minimize noise in the newborn's environment. D. Administer naloxone to the newborn.

Correct Answer is C

Explanation

A) Swaddle the newborn with his legs extended: This is not the appropriate way to swaddle a newborn. Swaddling should typically include flexing the legs to promote comfort and security, rather than extending them, which may be uncomfortable and less calming.

B) Maintain eye contact with the newborn during feedings: While establishing a bond with the newborn is important, excessive eye contact can overstimulate a newborn experiencing neonatal abstinence syndrome. The focus should be on creating a calming environment.

C) Minimize noise in the newborn's environment: This action is critical for a newborn experiencing neonatal abstinence syndrome, as these infants can be sensitive to stimuli. Reducing noise helps create a more soothing environment, which can alleviate symptoms of withdrawal.

D) Administer naloxone to the newborn: Naloxone is used to reverse opioid overdose, but it is not appropriate for routine treatment of neonatal abstinence syndrome. Management typically includes supportive care and, in some cases, pharmacologic treatment specific to the infant’s symptoms, rather than naloxone.

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A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

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