A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of an infant. Which of the following instructions should the nurse include?

Provide a pacifier for nonnutritive sucking.

Warm the formula in the microwave prior to administration.

Change the gastrostomy tube every 3 days.

Place the infant in a supine position after the feeding.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Provide a pacifier for nonnutritive sucking: Offering a pacifier promotes nonnutritive sucking, which supports oral motor development and provides comfort for the infant during gastrostomy tube feedings. This practice can help the infant transition more easily to oral feeding later.

B. Warm the formula in the microwave prior to administration: Warming formula in the microwave is unsafe because it can create hot spots that may burn the infant’s mouth or esophagus. Formula should be warmed using a bottle warmer or by placing the container in warm water.

C. Change the gastrostomy tube every 3 days: Routine gastrostomy tube replacement every 3 days is unnecessary and can cause trauma. Tubes are generally changed according to manufacturer recommendations or when malfunction or blockage occurs.

D. Place the infant in a supine position after the feeding: Infants should be kept in an upright or semi-upright position during and after feedings to reduce the risk of aspiration. Supine positioning increases the likelihood of reflux and respiratory complications.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Rationale:

• Platelet count: A drop in platelet count occurs in both preeclampsia and HELLP syndrome because of vascular endothelial damage leading to platelet aggregation and consumption. In HELLP, thrombocytopenia is often more severe, typically <100,000/mm³.

• Alanine aminotransferase (ALT): Elevated ALT reflects hepatocellular injury. It is a hallmark of HELLP syndrome (the “EL” = Elevated Liver enzymes) due to hepatic ischemia and microvascular damage, whereas in preeclampsia it may remain normal or only mildly elevated.

• Blood pressure: Hypertension (≥140/90 mm Hg) is the defining feature of preeclampsia and is also commonly seen in HELLP syndrome, which usually evolves from severe preeclampsia.

• Hemoglobin: Hemolysis (“H” in HELLP) results in decreased hemoglobin levels. In preeclampsia, hemoglobin levels are typically normal unless there is concurrent hemoconcentration or progression to HELLP syndrome.

A. Obtain a 12-lead ECG for the client. B. Administer sublingual nitroglycerin to the client. C. Measure the client's vital signs. D. Have the client stop walking and sit down.

Correct Answer is D

Explanation

Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.

B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.

C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.

D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.

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A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of an infant. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

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Correct Answer is D

Explanation

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