A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?

Formula should be changed to whole milk when the infant is 9 months old.

Formula that remains in the bottle should be used for one more feeding.

If the infant turns away after taking most of the feeding, stop the feeding.

If the infant is gaining weight too rapidly, dilute the formula.

Answer and Explanation

The Correct Answer is C

Choice A reason: Formula should not be changed to whole milk until the infant is 12 months old, as whole milk does not provide enough iron and other nutrients for the infant's growth and development. Whole milk can also cause intestinal bleeding and increase the risk of allergies in infants younger than 12 months.

Choice B reason: Formula that remains in the bottle should not be used for another feeding, as it can harbor bacteria and cause infection. Any formula that is not consumed within one hour of preparation or feeding should be discarded.

Choice C reason: If the infant turns away after taking most of the feeding, it is a sign that the infant is full and satisfied. The nurse should instruct the parents to stop the feeding and burp the infant. Forcing the infant to finish the bottle can cause overfeeding and vomiting.

Choice D reason: If the infant is gaining weight too rapidly, diluting the formula is not a safe or effective solution. Diluting the formula can cause water intoxication, electrolyte imbalance, and malnutrition in the infant. The nurse should advise the parents to consult with the infant's doctor about the appropriate amount and type of formula for the infant.

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Correct Answer is C

Explanation

Choice C reason: Flushing the tubing with water after each feeding is important to prevent clogging, maintain patency, and clear any residual formula from the tube. It also helps to prevent bacterial growth and infection.

Choice A reason: Wearing sterile gloves during a feeding is not necessary, as enteral feedings are not considered sterile procedures. Clean gloves are sufficient to prevent contamination and protect the nurse and the client.

Choice B reason: Chilling the feeding prior to administering is not recommended, as cold formula can cause abdominal cramping, discomfort, and diarrhea. The formula should be at room temperature or slightly warmed before giving it to the client.

Choice D reason: Positioning the client upright prior to a feeding is correct, but it is not enough. The client should remain upright for at least 30 minutes after the feeding as well, to prevent aspiration, reflux, and nausea.

A. Firm grip bilaterally B. Fatigue C. 2+ deep tendon reflexes D. Urine output 25 mL/hr

Correct Answer is A

Explanation

Choice A reason: A firm grip bilaterally indicates that the client has normal muscle strength and function, which can be impaired by hypernatremia. Hypernatremia can cause muscle weakness, twitching, and spasms due to the effects of high sodium levels on the nerve impulses.

Choice B reason: Fatigue is not a sign of effective treatment for hypernatremia. Fatigue can be a symptom of hypernatremia, as well as dehydration, infection, or other conditions. The nurse should assess the client for other causes of fatigue and monitor their vital signs and fluid status.

Choice C reason: 2+ deep tendon reflexes are not a sign of effective treatment for hypernatremia. 2+ deep tendon reflexes are considered normal and do not indicate any changes in the client's condition. The nurse should assess the client for other signs of improvement or deterioration, such as mental status, urine output, and serum sodium levels.

Choice D reason: Urine output 25 mL/hr is not a sign of effective treatment for hypernatremia. Urine output 25 mL/hr is below the normal range of 30 to 50 mL/hr and indicates oliguria, which can be a complication of hypernatremia. Oliguria can result from dehydration, kidney damage, or reduced blood flow to the kidneys due to hypernatremia. The nurse should notify the provider and administer fluids as prescribed.

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A nurse is providing teaching about formula feeding to the parents of an infant. Which of the following instructions should the nurse include?

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