A nurse is contributing to the plan of care for a toddler who is receiving intermittent enteral feedings. Which of the following interventions should the nurse include?
Maintain the child in a supine position.
Discard gastric residuals prior to each feeding
Warm the feeding in the microwave oven for 15 seconds
Administer the feeding to the child at 10 mL/min.
The Correct Answer is D
A. Maintain the child in a supine position: The child should not be in a supine (lying flat) position during enteral feedings, as this increases the risk of aspiration. The child should be positioned upright or at least 30 to 45 degrees to reduce this risk.
B. Discard gastric residuals prior to each feeding: While it is important to check gastric residuals before each feeding to ensure proper gastric emptying, residuals should not automatically be discarded. Depending on the volume of residuals, the feeding may need to be delayed or adjusted rather than discarded.
C. Warm the feeding in the microwave oven for 15 seconds: Feeding should never be warmed in the microwave because it can cause uneven heating, which could lead to burns. Feedings should be warmed using a safe method, such as a warm water bath, to ensure even temperature.
D. Administer the feeding to the child at 10 mL/min: Administering the feeding at a slow and controlled rate, such as 10 mL/min, is recommended to prevent discomfort and reduce the risk of aspiration. This rate allows the digestive system to process the feeding properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer the vaccine in the vastus lateralis muscle using a 25-mm (1-in) needle: For infants, the vastus lateralis muscle in the thigh is the preferred site for intramuscular (IM) vaccinations, including the Hib vaccine. A 25-mm (1-in) needle is an appropriate length for this muscle in a 6-month-old infant.
B. Administer the vaccine subcutaneously in the abdomen using a 16-mm (5/8-in) needle: The Hib vaccine is not administered subcutaneously. It is an intramuscular injection, and the abdomen is not the recommended site for this vaccine.
C. Administer the vaccine subcutaneously in the upper arm using a 13-mm (1/2-in) needle: The Hib vaccine is administered intramuscularly, not subcutaneously. The upper arm is used for intramuscular injections in older children. A 13-mm needle is too short for an intramuscular injection in the vastus lateralis.
D. Administer the vaccine in the dorsogluteal muscle using a 51-mm (2-in) needle: The dorsogluteal muscle is not recommended for infants due to the risk of damaging the sciatic nerve. A 2-inch needle is too long for this area in an infant.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Consult the child life specialist for guidance: A child life specialist can help the parent navigate the difficult conversation with their adolescent, providing strategies for addressing sensitive topics like metastasis and death.
- Reinforce teaching to the parent regarding the adolescent's potential emotional responses: Educating the parent on common emotional responses helps them prepare for and better support their adolescent through this challenging time.
Rationale for Incorrect Choices:
- Encourage the parent to hide their emotions from their adolescent: Hiding emotions can create barriers to trust and communication, which can make the adolescent feel isolated or confused.
- Instruct the parent to withhold the test results from their adolescent: Withholding important information can prevent the adolescent from understanding their condition and making informed decisions about their care.
- Discourage the parent from discussing the possibility of death with their adolescent: Avoiding discussions about death can prevent the adolescent from processing their emotions and understanding the reality of their situation.
- Collaborate with the RN to initiate a referral for admission to hospice care: Hospice care should only be considered after emotional support and clear communication have been established, not prematurely without addressing emotional needs first.
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