A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings.
To maintain normal growth and development of the infant, which action should the nurse include?

Offer a pacifier for non-nutritive sucking.

Use sterile technique during feedings.

Ensure placement of the nasogastric tube with an abdominal x-ray.

Speak to the healthcare provider about instituting physical therapy.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.

Choice B rationale

Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.

Choice C rationale

While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.

Choice D rationale

Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .

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Correct Answer is A

Explanation

Choice A rationale

Projectile vomiting in an infant with an olive-like mass in the abdomen suggests pyloric stenosis. This condition causes severe vomiting due to gastric obstruction. It's a hallmark symptom and requires monitoring and surgical intervention.

Choice B rationale

While arching the back can occur in various conditions, it is not specifically indicative of pyloric stenosis. It could be a sign of discomfort or other neurological issues but not directly related to the gastrointestinal obstruction seen in pyloric stenosis.

Choice C rationale

Frequent pauses during feeding are common in many infant conditions and are not specific to pyloric stenosis. They indicate general feeding difficulties but are not diagnostic of this particular condition.

Choice D rationale

Coffee-ground emesis indicates bleeding in the gastrointestinal tract but is not typical of pyloric stenosis. The hallmark sign is non-bloody, forceful vomiting due to gastric outlet obstruction.

A. Gather supplies for an IV infusion. B. Prepare for anorectal surgery. C. Measure abdominal circumference. D. Monitor strict urinary output.

Correct Answer is C

Explanation

Choice A rationale

Gathering supplies for an IV infusion is essential in many cases but not the priority here. Measuring abdominal circumference helps determine if there is abdominal distention indicating a possible blockage, which could suggest a condition like Hirschsprung's disease. Early detection and appropriate intervention are critical, making it the first action.

Choice B rationale

Preparing for anorectal surgery may be necessary if a diagnosis like Hirschsprung’s disease or imperforate anus is confirmed. However, the initial priority is to assess for signs of abdominal distention by measuring the circumference, providing crucial information for the next steps.

Choice D rationale

Monitoring strict urinary output is important for overall fluid balance and identifying complications related to fluid shifts. However, in this scenario, the priority action is to assess for abdominal distention, a potential sign of a serious underlying condition causing the symptoms observed in the infant.

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A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings.
To maintain normal growth and development of the infant, which action should the nurse include?