A nurse is caring for an infant who has heart failure and is formula-fed. Which of the following nursing interventions is appropriate to meet the infant's nutritional needs?
Feed the infant at the first sign of hunger.
Use a firm nipple on the bottle when feeding.
Dilute the formula with water to half strength.
Thicken the formula with 1 tsp of rice cereal per ounce.
The Correct Answer is A
A. Infants with HF tire easily; feeding them early, before they are overly fatigued and crying, conserves energy and helps them take in more nutrition. Smaller, more frequent feedings are often recommended.
B. A firm nipple may require more effort to suck, which can be tiring for an infant with heart failure. A softer nipple may be more appropriate.
C. Diluting the formula with water can lead to inadequate caloric intake and nutritional deficiencies. Formula should be prepared according to instructions to ensure proper nutrition.
D. Thickened feeds are sometimes used for reflux, not HF. Adding cereal increases caloric intake but also makes sucking/swallowing more difficult, increasing energy expenditure.
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Related Questions
Correct Answer is C
Explanation
A. Nasal discharge negative for glucose indicates that there is no cerebrospinal fluid (CSF) leakage, which is a positive sign. While it is important to note, it is not the priority in this situation.
B. A negative Babinski reflex is a normal finding in children older than 2 years. It does not indicate an acute issue and is not the priority.
C. Asymmetric pupils can be a sign of increased intracranial pressure or a serious brain injury, making this the priority finding. It requires immediate attention to prevent further complications.
D. A 2 cm scalp laceration, while needing medical attention, is not life-threatening and is not the highest priority compared to potential brain injury indicated by asymmetric pupils.
Correct Answer is A
Explanation
A. "You should be prepared to answer your child's questions about dying." is appropriate because children at this age may have questions about death and dying. It is important for the guardian to be honest and provide age-appropriate answers to help the child understand and cope with their situation.
B. While younger children often view death as temporary, a 10-year-old child typically has a more developed understanding of the finality of death. This statement might not be accurate for this age group.
C. Hiding grief is not recommended as it can create an atmosphere of secrecy and fear. It is better to model healthy expressions of emotions and provide support for the child's feelings.
D. Limiting visits between siblings may not be necessary and can be detrimental. Sibling support can be very important for both the ill child and the sibling, providing comfort and a sense of normalcy.
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