A nurse is contributing to the plan of care for an infant who has heart failure. Which of the following interventions should the nurse recommend?
Provide feedings every 3 hr.
Dilute formula to half strength.
Place the infant in lateral position during feeding.
Implement bolus gavage feedings.
The Correct Answer is A
A. Infants with heart failure may experience fatigue during feeding, so smaller, more frequent feedings are recommended to prevent exhaustion and ensure adequate nutrition. Feedings every 3 hours are typically recommended to maintain a steady intake without overexertion.
B. Diluting formula to half strength is not recommended for an infant with heart failure, as it can lead to malnutrition and insufficient caloric intake. The formula should be provided at normal strength.
C. Placing the infant in a lateral position during feeding could be unsafe, as it may increase the risk of aspiration. The infant should generally be fed in an upright or semi-upright position to reduce aspiration risk and promote optimal digestion.
D. Bolus gavage feedings are typically used for infants who are unable to feed orally due to medical conditions, but for a child with heart failure who is feeding orally, more frequent and smaller feedings would be preferable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The Poker Chip Tool is used to assess pain in children who can understand the concept of "a few" to "lots" of pain, typically in older children. It is not appropriate for infants or toddlers.
B. The Color tool is used for children who can associate color with pain intensity, but it is generally for older children who can understand this system, not for infants.
C. The Numeric scale is designed for children who are old enough to understand and use numbers (typically older than 8 years). An 18-month-old would not be able to understand this scale.
D. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is specifically designed to assess pain in infants and nonverbal children. It uses behavioral indicators to rate pain intensity and is appropriate for an 18-month-old toddler.
Correct Answer is A
Explanation
A. A 2-year-old toddler should have more than six teeth by this age, and the eruption of only six teeth is a delay in expected development. Most children have 16 teeth by age 2.
B. Using two- or three-word phrases is appropriate for a 2-year-old and is a sign of normal language development.
C. Building a tower of six to seven cubes is an appropriate developmental milestone for a 2-year-old and indicates normal motor development.
D. Being able to pick up objects without falling is a normal gross motor skill for a 2-year-old.
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