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.

Answer and Explanation

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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Correct Answer is A

Explanation

"I should start trying to breastfeed within an hour of having my baby.” Choice A reason:

The client's statement indicates an understanding of the teaching because initiating breastfeeding within the first hour after birth is crucial for successful breastfeeding. This early initiation allows the baby to receive colostrum, which is rich in nutrients and antibodies, supporting the baby's immune system and providing essential nutrition during the initial stages of life. Additionally, early breastfeeding helps establish a strong bond between the mother and the baby while promoting the baby's suckling reflex.

Choice B reason:

The statement in Choice B is incorrect. Formula feeding between breastfeedings is not recommended in the early stages of breastfeeding, especially if the baby loses 5 percent of their birth weight. Newborns often lose some weight initially, which is normal, and it can be regained through effective breastfeeding. Supplementing with formula may interfere with establishing a good milk supply and the baby's ability to latch properly.

Choice C reason:

This statement in Choice C is incorrect. During breastfeeding sessions, it's essential for the baby to nurse on one breast fully before switching to the other breast. Allowing the baby to nurse for at least 10-15 minutes on each breast ensures they receive the hindmilk, which is higher in fat and essential for the baby's growth and development.

Choice D reason:

The statement in Choice D is incorrect. Offering a pacifier right after breastfeeding might interfere with the baby's feeding cues and lead to decreased breastfeeding frequency.

Newborns may suck for non-nutritive reasons, and offering a pacifier too soon can hinder proper breastfeeding establishment, as they may satisfy their sucking needs with the pacifier rather than nursing at the breast.

A. Presence of Moro reflex. B. Birth weight has doubled. C. Closed posterior fontanel. D. Able to sit unsupported. E. Able to move from back to front.

Correct Answer is ["A"]

Explanation

Choice A reason: The correct answer is choice A. The nurse should expect the presence of the Moro reflex in a 6-month-old infant. The Moro reflex is a normal primitive reflex seen in infants up to about 6 months of age. When the infant experiences a sudden loss of support or a loud noise, they react by extending their arms and legs and then pulling them back in, as if trying to grasp onto something. This reflex is an important indicator of the baby's neurological development.

Choice B reason:

The birth weight doubling by 6 months of age is a typical growth milestone for infants. However, this statement is not correct in the context of the question, as it is not something the nurse should "expect” during a well-child visit. Instead, it is a general developmental milestone that healthcare providers monitor over time.

Choice C reason:

The correct answer is choice C. The nurse should expect the posterior fontanel to be closed in a 6-month-old infant. Fontanels are soft spots on a baby's skull that allow for brain growth during early development. The posterior fontanel, located at the back of the head, is typically closed by 6 months of age.

Choice D reason:

The correct answer is choice D. At 6 months of age, many infants can sit unsupported. However, not all infants achieve this milestone at the exact same age. Some may achieve it a bit earlier, while others might take a little more time. It is essential for the nurse to assess the infant's developmental progress and provide appropriate guidance to the parents.

Choice E:

The correct answer is choice E. By 6 months of age, some infants may be able to move from their back to their front. This is usually accomplished through rolling over. However, like other developmental milestones, the age at which infants achieve this can vary. Therefore, while the nurse may expect this ability in some infants, it is not something that all 6-month- old infants will have mastered at the time of the well-child visit.

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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?

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