A nurse is preparing to administer an intermittent enteral feeding to a child who has an NG tube in place. Which of the following actions should the nurse take first?
Place the child in an upright position.
Verify the position of the NG tube.
Determine the gastric residual volume.
Flush the child's NG tube with sterile water.
The Correct Answer is B
Choice A reason:
The nurse should prioritize Choice B over Choice A as it is essential to first confirm the correct placement of the NG tube before proceeding with any other actions. If the tube is not correctly positioned, administering the enteral feeding can lead to potential complications, such as aspiration, which can be life-threatening. Therefore, it is crucial to ensure the NG tube's proper placement before moving forward with the feeding
Choice B reason:
This option takes precedence as verifying the NG tube's position is a fundamental step in the enteral feeding process. The nurse must use appropriate methods, such as X-ray or pH testing, to confirm that the tube is in the stomach and not in the respiratory tract or elsewhere. This verification ensures the safety and effectiveness of the feeding procedure and prevents potential harm to the child.
Choice C reason:
While checking the gastric residual volume (GRV) is an important step in some cases, it should be done after confirming the NG tube's proper placement (Choice B). GRV provides information about the amount of feeding left in the stomach and helps in assessing tolerance to the feeding. However, if the NG tube is misplaced, determining GRV becomes irrelevant as the feeding would not be going to the intended location.
Choice D reason:
Flushing the child's NG tube with sterile water is an appropriate step during the enteral feeding process but should be done after verifying the tube's position (Choice B). Flushing ensures that the tube is patent and free from any obstructions, allowing the feeding to pass through smoothly. However, again, if the NG tube is incorrectly positioned, flushing it would not address the underlying issue.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C reason: The infant makes babbling sounds. At 6 months of age, it is typical for infants to engage in babbling sounds. Babbling is a significant milestone in language development during infancy. It involves the repetition of consonant-vowel combinations (e.g., "ba-ba,”. "ma-ma") and is an essential precursor to later language skills, such as forming words and sentences. The nurse should expect the 6-month-old infant to be making these babbling sounds as part of their normal development.
Choice A reason:
The infant has a pincer grasp. A pincer grasp is the ability to pick up small objects using the thumb and index finger. This fine motor skill typically develops around 9 to 12 months of age. At 6 months old, infants have not yet acquired the pincer grasp. Therefore, the nurse should not expect the 6-month-old infant to demonstrate this skill during the assessment.
Choice D reason:
The infant crawls on their hands and knees. Crawling is a gross motor skill that usually emerges between 7 to 10 months of age. While some infants may start crawling earlier or later, it is not a skill that is typically present in a 6-month-old. Therefore, the nurse should not anticipate the 6-month-old infant to be crawling on their hands and knees during the assessment.
Choice B reason:
The infant drops objects with the expectation of someone picking them up. This behavior, known as "object permanence,”. is a cognitive milestone that develops around 8 to 12 months of age. At 6 months old, infants have not yet fully developed this concept. They might drop objects as part of their exploratory behavior, but they do not yet understand the expectation of someone picking them up. Therefore, the nurse should not expect the 6- month-old infant to exhibit this specific behavior during the assessment.
Correct Answer is D
Explanation
Choice A reason:
The nurse should not reinforce to the client that they should not breastfeed after delivery. Group B streptococcus (GBS) is not transmitted through breast milk. It is crucial for infants born to GBS-positive mothers to receive appropriate prophylaxis, but breastfeeding is not contraindicated.
Choice B reason:
The nurse should maintain contact precautions for the client. Group B streptococcus is a highly contagious bacterium, and taking precautions can help prevent its transmission to other patients and healthcare workers.
Choice C reason:
The nurse does not need to obtain a pharyngeal culture from the client. Group B streptococcus colonization typically occurs in the genital and gastrointestinal tracts, not in the pharynx. Therefore, a pharyngeal culture would not be relevant in this situation.
Choice D reason:
This is the correct action the nurse should take. The client tested positive for group B streptococcus, which puts the newborn at risk of infection during labor and delivery. The standard protocol is to administer intravenous antibiotic prophylaxis to the mother during labor to reduce the risk of transmission to the baby.
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