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 ["C","D"]
Explanation
A. "There is nothing we can do to minimize overgrowth of their gum tissue.": Incorrect. Gingival hyperplasia is a known side effect of phenytoin, but good oral hygiene and regular dental care can help minimize its severity.
B. "They will need to take 400 IU of vitamin E while on this medication.": Incorrect. Routine vitamin E supplementation is not standard or necessary with phenytoin unless specifically indicated by a provider.
C. "We will need to periodically have their blood drawn to check phenytoin levels.": Correct. Phenytoin has a narrow therapeutic index, so serum drug levels must be monitored regularly to avoid toxicity or subtherapeutic dosing.
D. "This medication may cause their eyes to, at times, move quickly back and forth.": Correct. Nystagmus is a known dose-related side effect of phenytoin, especially at higher levels.
E. "This drug won't decrease the effectiveness of their oral contraceptive medication.": Incorrect. Phenytoin is a hepatic enzyme inducer and can reduce the effectiveness of hormonal contraceptives, so alternate or additional contraceptive methods should be recommended.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}
Explanation
Rationale:
- Type of cough: The characteristic "barking" cough is typical of acute laryngotracheobronchitis (also known as croup), which affects the upper airways and results in a harsh, barking cough. Pneumonia causes a productive cough, which is not noted here. The non-productive cough in this case is more indicative of laryngotracheobronchitis.
- Fever: A low-grade fever is common in acute laryngotracheobronchitis and is consistent with this case (38.2°C to 38.9°C). Pneumonia can also cause fever, especially a higher-grade fever, but the fever.
- Stridor: Inspiratory stridor is a hallmark sign of acute laryngotracheobronchitis, caused by narrowing of the upper airway, leading to a high-pitched sound when breathing in. Stridor is not typically associated with pneumonia, as pneumonia primarily affects the lungs and causes symptoms like cough, difficulty breathing, and chest pain rather than airway narrowing.
- Irritability: Irritability is common in acute laryngotracheobronchitis due to discomfort from the cough, difficulty breathing, and fever. Irritability can also be seen in pneumonia, particularly in young children who may be uncomfortable due to fever, difficulty breathing, and general malaise.
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