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. An increased pulse may occur as a response to a variety of factors, including the infection or the administration of the antibiotic, but it does not necessarily indicate a severe allergic reaction.
B. A maculopapular rash could be a mild allergic reaction or side effect to the antibiotic, but it is not as immediately concerning as wheezing, which could indicate an anaphylactic reaction.
C. A headache can be a side effect of antibiotics, but it is not typically an urgent concern unless accompanied by other signs of severe allergic reactions.
D. Wheezing is a critical finding and could indicate an allergic reaction or anaphylaxis, a potentially life-threatening condition. This symptom requires immediate attention and is the priority to report to the provider.
Correct Answer is D
Explanation
A. While it is a good idea to wear a helmet, the color does not significantly impact safety. The helmet should fit securely and cover the forehead, not the ears.
B. Riding against traffic is unsafe. Cyclists should always ride in the same direction as traffic to ensure they are visible to drivers.
C. The child should always walk the bicycle through crosswalks and intersections to ensure safety and better visibility to drivers.
D. Ensuring the balls of the feet touch the ground while seated on the bicycle helps the child maintain balance and provides a safer, more controlled ride.
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