A nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics.
The infant expels a bloody stool.
What nursing action should the nurse implement?
Obtain a rectal temperature.
Institute contact precautions.
Decrease the amount of the feeding.
Assess for abdominal distention.
The Correct Answer is B
Institute contact precautions. This is because the infant may have necrotizing enterocolitis (NEC), which is the most common cause of bloody stool in preterm infants.
NEC is a serious condition that involves inflammation and necrosis of the intestinal wall and can lead to perforation, sepsis, and death. NEC is also a potential source of infection for other infants in the NICU, so contact precautions are necessary to prevent cross-contamination.
Choice A is wrong because obtaining a rectal temperature is not indicated for an infant with bloody stool. Rectal temperature can cause irritation and bleeding of the rectal mucosa and can also increase the risk of perforation if there is intestinal necrosis.
Choice C is wrong because decreasing the amount of the feeding is not enough to manage an infant with bloody stool.
The infant may need to have the feeding stopped completely and receive parenteral nutrition until the bowel heals. Decreasing the feeding may also compromise the infant’s growth and development.
Choice D is wrong because assessing for abdominal distention is not a nursing action but a nursing assessment.
Abdominal distention is a common sign of feeding intolerance and NEC, but it is not specific or sensitive enough to diagnose the condition. Other signs and symptoms of NEC include bile-stained or bloody gastric residuals, emesis, diarrhea, temperature instability, apnea, bradycardia, hypotension, and lethargy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reticulocyte count 2%.
A reticulocyte count measures the percentage of immature red blood cells (RBCs) in the blood.A low reticulocyte count indicates that the bone marrow is not producing enough RBCs, which is a characteristic feature of anemia of prematurity (AOP).A normal reticulocyte count for preterm infants is 3-6%.
Choice A is wrong because hemoglobin 10 g/dL is within the normal range for preterm infants.
Hemoglobin is the protein in RBCs that carries oxygen.
A low hemoglobin level indicates anemia.
Choice B is wrong because hematocrit 30% is within the normal range for preterm infants.
Hematocrit is the percentage of blood volume that is occupied by RBCs.
A low hematocrit level indicates anemia.
Choice D is wrong because platelet count 150,000/mm3 is within the normal range for preterm infants.
Platelets are cell fragments that help with blood clotting.
A low platelet count indicates thrombocytopenia, which is a different condition from anemia.
Correct Answer is A
Explanation
This is because newborns with hypoglycemia need to receive adequate nutrition to raise their blood glucose levels and prevent neurologic damage.Early feeding also helps establish breast milk supply for nursing mothers.
Choice B is wrong because feeding the baby only when he cries may delay the intake of glucose and worsen the hypoglycemia.Newborns with hypoglycemia should be fed on demand or at least every 2 to 3 hours.
Choice C is wrong because feeding the baby every 6 hours is too infrequent and may cause prolonged hypoglycemia.Newborns with hypoglycemia should be fed on demand or at least every 2 to 3 hours.
Choice D is wrong because feeding the baby with glucose water may not provide enough calories and nutrients for growth and development.Newborns with hypoglycemia should be fed with breast milk or formula.Glucose water may be used as a temporary measure until breast milk or formula is available.
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