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 A
Explanation
Choice A rationale:
Apply cold packs to the lower abdomen. This is the correct answer because applying cold packs to the lower abdomen can help alleviate dysmenorrhea (painful menstrual cramps). Cold therapy helps to constrict blood vessels, reducing blood flow to the area and thus reducing pain. It's a non-pharmacological approach to managing menstrual cramps.
Choice B rationale:
Increase daily intake of fat. Increasing fat intake is not a recommended approach for managing dysmenorrhea. Balanced nutrition is important, but increasing fat intake is unlikely to significantly impact menstrual cramps. Other strategies are more effective.
Choice C rationale:
Massage the lower back area. Massaging the lower back can help with muscle relaxation and may provide some relief, but it is not as effective as applying cold packs to the lower abdomen for dysmenorrhea. Cold packs specifically target blood flow reduction to the area of pain.
Choice D rationale:
Limit physical activity. While it's generally a good idea to avoid strenuous physical activity during periods of intense pain, limiting physical activity alone is not the most effective strategy for managing dysmenorrhea. Cold packs and other interventions are more likely to provide relief.
Correct Answer is D
Explanation
Choice A rationale:
Edema. Edema, the accumulation of fluid in the tissues, is not the primary indicator of compartment syndrome. While edema can occur due to various reasons, it's not specific to compartment syndrome. Compartment syndrome primarily involves increased pressure within a closed space (muscle compartment), which can compromise blood circulation and nerve function.
Choice B rationale:
Mottling. Mottling refers to a patchy, bluish discoloration of the skin that occurs due to poor blood circulation and is often seen in critically ill patients. While it might indicate circulatory issues, it's not a direct sign of compartment syndrome. Compartment syndrome is more closely associated with symptoms such as severe pain, numbness, and decreased or absent pulses.
Choice C rationale:
Urticaria. Urticaria, also known as hives, is a skin rash characterized by raised, itchy, and red or white welts. It is typically caused by an allergic reaction or other factors such as medications. Urticaria is unrelated to compartment syndrome, which involves the compression of nerves and blood vessels within a closed anatomical compartment, leading to ischemia and potential tissue damage.
Choice D rationale:
Pulselessness. Pulselessness is a critical sign that the nurse should monitor when conducting a circulatory check for compartment syndrome. Compartment syndrome occurs when there is increased pressure within a confined space (muscle compartment), leading to compromised blood flow and oxygen delivery to the tissues. The lack of a palpable pulse in the affected area suggests that blood flow is severely compromised. This is a late sign of compartment syndrome and requires immediate intervention to prevent tissue necrosis and long-term complications.
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