A nurse is caring for an infant who receives intermittent enteral feedings through a gastrostomy tube.
Which of the following actions should the nurse take when administering a feeding? (Select all that apply.).
Offer the infant a pacifier during feedings.
Check for residual volumes by aspirating stomach contents.
Place the infant in supine position.
Instill the formula over a period of 30 to 45 min.
Heat the formula to 39° C (102° F) prior to administration.
Correct Answer : A,B,D

A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation

This is because oxygen saturation below 90% indicates that the infant is not getting enough oxygen and central cyanosis (bluish color of the skin due to lack of oxygen) is a sign of severe respiratory distress.
Both of these findings require immediate medical attention.
Choice A is wrong because cough or difficulty in breathing, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice C is wrong because severe respiratory distress (e.g grunting, very severe chest indrawing), while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice D is wrong because signs of pneumonia with a general danger, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Correct Answer is D
Explanation
Checking the toddler’s ID band against the medical record is the best way to confirm their identity before administering medication.
This ensures that the right medication is given to the right patient.
Choice A is wrong because room numbers can change and are not a reliable way to identify a patient.
Choice B is not the best answer because it relies on another person’s knowledge and memory, which can be fallible.
Choice C is wrong because parents may be stressed or distracted and may not provide accurate information.
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