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 D
Explanation
A. Lack of subcutaneous fat: Lack of subcutaneous fat may indicate neglect or malnutrition, but it is not a specific sign of sexual abuse.
B. Unexplained illness: Unexplained illness could be related to various conditions, including neglect or medical issues, but it is not a specific indicator of sexual abuse.
C. Poor personal hygiene: Poor personal hygiene can be a sign of neglect but does not directly point to sexual abuse. It could be due to lack of supervision, resources, or care rather than abuse.
D. Recurrent urinary tract infections: Recurrent urinary tract infections (UTIs) can be a red flag for sexual abuse, especially in young children. These infections may be caused by inappropriate sexual contact or injury to the genital area.
Correct Answer is C
Explanation
A. Show the child's parent how to release tension on the bars: The tension on the halo vest is adjusted by the healthcare provider, not by the parent. The nurse should not instruct the parent to release tension, as improper adjustments can lead to complications.
B. Remove the vest for the child to sleep at night: The halo vest should remain in place at all times, including during sleep, to maintain proper cervical traction and stabilization. Removing it may interfere with the healing process and cause further injury.
C. Check the child's pupillary response: Monitoring the pupillary response is important in a child with cervical traction to assess for any neurological changes. It helps identify signs of increased intracranial pressure or other neurological complications.
D. Apply a cervical collar if the child reports neck pain: The halo vest itself is designed to stabilize the neck, and the application of a cervical collar without provider guidance could interfere with the proper use of the traction system.
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