A nurse is preparing to administer nasogastric tube feedings to a 2-month-old infant. Which of the following actions should the nurse plan to take?
Stabilize the tube by taping it to the infant's cheek.
Position the infant in a supine position during feedings.
Aspirate residual fluid from the infant's stomach and discard.
Microwave the infant's formula to a temperature of 41° C (105.8° F).
The Correct Answer is A
Choice A rationale:
Stabilizing the nasogastric tube by taping it to the infant's cheek is a crucial step in preventing accidental removal or displacement of the tube during feedings. Infants are known for their active movements, which could lead to unintentional removal of the tube. Taping the tube securely helps maintain its proper placement and ensures the delivery of nutrients.
Choice B rationale:
Positioning the infant in a supine (lying on the back) position during feedings is not recommended. This position could lead to an increased risk of aspiration, where the feedings could enter the airway and lungs, causing respiratory issues. The recommended position for nasogastric tube feedings is semi-upright or upright to minimize this risk.
Choice C rationale:
Aspirating residual fluid from the infant's stomach and discarding it is not standard practice for nasogastric tube feedings. Aspirating can introduce the risk of infection or cause irritation to the stomach lining. Additionally, residual fluid can provide valuable information about the infant's digestion and absorption, and its presence should be taken into consideration when adjusting feedings.
Choice D rationale:
Microwaving the infant's formula to a temperature of 41°C (105.8°F) is not safe. Formula should be warmed gently using warm water or a bottle warmer to avoid overheating, which could burn the infant's mouth and esophagus. Microwaving can cause uneven heating and lead to hot spots within the formula, posing a risk of burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hct 45% (Choice A) refers to the hematocrit level, which measures the proportion of blood volume occupied by red blood cells. While dehydration can lead to elevated hematocrit due to hemoconcentration, a hematocrit value of 45% is within the normal range for both males and females. Dehydration might cause a mild increase, but more significant elevations would be expected in cases of severe dehydration.
Choice B rationale:
Urine specific gravity 1.035 (Choice B) is an indicator of concentrated urine, which is a characteristic finding in dehydration. Dehydration reduces the body's water content, leading to more concentrated urine with higher specific gravity values. A normal range for urine-specific gravity is typically between 1.005 and 1.030.
Choice C rationale:
Capillary refill of less than 2 seconds (Choice C) is not a finding consistent with dehydration. Capillary refill time measures the time it takes for color to return to the nailbed after pressure is applied. Prolonged capillary refill time might indicate poor peripheral perfusion, which can be a sign of dehydration, but a refill time of less than 2 seconds is considered within the normal range.
Choice D rationale:
A urine output of 35 ml/hr (Choice D) is not indicative of dehydration. In fact, a urine output of 35 ml/hr is relatively normal and suggests adequate fluid intake and hydration. Dehydration would typically result in reduced urine output as the body conserves water.
Correct Answer is D
Explanation
Choice A rationale:
Tinnitus is the perception of noise or ringing in the ears. It can be caused by various factors, including exposure to loud noises, ear infections, and certain medications. However, tinnitus is not a commonly reported adverse effect of albuterol, which is a bronchodilator used to treat conditions like asthma and other respiratory disorders.
Choice B rationale:
Constipation is not a commonly reported adverse effect of albuterol. Albuterol primarily acts on the smooth muscles of the airways to relax and dilate them, improving airflow. Constipation is more likely related to issues with the gastrointestinal system or certain medications, but it is not a direct consequence of albuterol use.
Choice C rationale:
Hypoglycemia, or low blood sugar, is not a known adverse effect of albuterol. Albuterol primarily affects the respiratory system and does not typically impact blood glucose levels. Hypoglycemia is more commonly associated with diabetes medications like insulin or certain oral hypoglycemic agents.
Choice D rationale:
Headache is a potential adverse effect of albuterol. While not everyone will experience a headache when taking albuterol, it can occur as a side effect in some individuals. Albuterol can stimulate the sympathetic nervous system, leading to effects such as increased heart rate and potential vasodilation, which could contribute to the development of a headache in some cases. It's important for the parents of a child taking albuterol to be aware of potential side effects and report them to the healthcare provider if they occur.
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