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
Discontinue the oxytocin (Pitocin) infusion.This is because the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction indicate alate deceleration, which is a sign offetal hypoxia.Oxytocin is a drug that stimulates uterine contractions and can causeuterine hyperstimulation, which reduces blood flow to the placenta and the fetus.By stopping the oxytocin infusion, the nurse can reduce the frequency and intensity of contractions and improve fetal oxygenation.
Choice A is wrong because administering oxygen via facemask may not be enough to reverse fetal hypoxia if oxytocin is still being infused.Choice B is wrong because placing the client on her left side may improve maternal blood flow to the placenta, but it will not reduce the effects of oxytocin on uterine activity.
Choice D is wrong because notifying the healthcare provider is not the most urgent action at this time.The nurse should first discontinue the oxytocin infusion and then notify the healthcare provider.
Normal ranges for FHR are 110 to 160 beats per minute, with a baseline variability of 6 to 25 beats per minute.
Normal ranges for uterine contractions are 2 to 5 contractions in 10 minutes, lasting
Correct Answer is C
Explanation
Jitteriness and poor feeding are common signs of hypoglycemia in a newborn.
Hypoglycemia is when the level of sugar (glucose) in the blood is too low.
Glucose is the main source of fuel for the brain and the body.In a newborn baby, low blood sugar can cause problems such as shakiness, blue tint to the skin, and breathing and feeding problems.
Choice A is wrong because hypertension and bradycardia are not typical symptoms of hypoglycemia in a newborn.
They may indicate other conditions such as heart problems or infection.
Choice B is wrong because diarrhea and vomiting are not specific symptoms of hypoglycemia in a newborn.
They may be caused by many other factors such as infection, food intolerance, or gastroesophageal reflux.
Choice D is wrong because hyperactivity and irritability are not usual symptoms of hypoglycemia in a newborn.
They may be signs of other conditions such as pain, hunger, or overstimulation.
Normal ranges for blood glucose levels in newborns vary depending on the age, gestational age, and feeding status of the baby.Most doctors consider blood glucose that is below 47 milligrams per deciliter (mg/dl) to be the definition of hypoglycemia in newborns.
However, some babies may need higher levels to prevent brain injury.
A doctor will monitor the blood glucose levels of a newborn at risk for hypoglycemia and treat accordingly.
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