A six-week-old infant is one day post-op for a pyloromyotomy for pyloric stenosis. The infant is started on the first oral feedings. Which of the following actions by the mother would most indicate a need for further nursing interventions?
The mother plans to burp the infant after feeding.
The mother plans to give five milliliters of water.
The mother plans to wrap the infant during feeding.
The mother plans to give thirty milliliters of water.
The Correct Answer is D
Choice A reason: This statement is incorrect, as burping the infant after feeding is not a nursing intervention, but a normal practice to prevent gas and discomfort. The nurse should encourage the mother to burp the infant gently after each feeding, and to avoid overfeeding or underfeeding the infant.
Choice B reason: This statement is incorrect, as giving five milliliters of water is not a nursing intervention, but a harmless amount of fluid for the infant. The nurse should inform the mother that water is not necessary for the infant, as breast milk or formula provides enough hydration and nutrition. However, the nurse should also reassure the mother that a small amount of water will not harm the infant.
Choice C reason: This statement is incorrect, as wrapping the infant during feeding is not a nursing intervention, but a comforting measure for the infant. The nurse should support the mother's bonding with the infant, and suggest ways to make the feeding experience more pleasant and relaxing for both of them. The nurse should also monitor the infant's temperature and avoid overheating.
Choice D reason: This statement is correct, as giving thirty milliliters of water is a nursing intervention that indicates a need for further education and guidance. The nurse should explain to the mother that giving too much water to the infant can cause water intoxication, which can lead to hyponatremia, seizures, or even death. The nurse should also teach the mother the signs and symptoms of water intoxication, such as irritability, lethargy, vomiting, or swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Somnolence, hypotension, and oliguria are signs of decompensated shock, which occurs when the body's compensatory mechanisms fail to maintain adequate tissue perfusion.
Choice B reason: Irritability, tachypnea, and hypotension are also signs of decompensated shock, as the respiratory rate increases to compensate for the low blood pressure and oxygen delivery.
Choice C reason: Irritability, capillary refill time > 2 seconds, and bradycardia are not typical signs of compensated shock, as the heart rate usually increases to maintain cardiac output and blood pressure.
Choice D reason: Irritability, tachycardia, and poor peripheral perfusion are signs of compensated shock, which occurs when the body tries to maintain adequate tissue perfusion by increasing the heart rate, constricting the peripheral blood vessels, and shunting blood to the vital organs.
Correct Answer is B
Explanation
Choice A reason: This is not a good choice. Adult heart disease can cause volume overload, but so can pediatric heart disease. Volume overload is a condition where the heart has to pump more blood than normal, which can lead to heart failure and pulmonary edema. Volume overload can be caused by various factors, such as valvular defects, hypertension, or anemia.
Choice B reason: This is the correct choice. Adult heart disease is usually acquired, meaning that it develops over time due to factors such as aging, lifestyle, or infection. Pediatric heart disease is usually congenital, meaning that it is present at birth due to genetic or environmental factors that affect the development of the heart.
Choice C reason: This is not a good choice. Heart failure can occur in both adult and pediatric heart disease. Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs, which can lead to symptoms such as fatigue, shortness of breath, and edema. Heart failure can be caused by various factors, such as coronary artery disease, cardiomyopathy, or arrhythmias.
Choice D reason: This is not a good choice. Digoxin is a drug that can be used for both adults and children with heart disease. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, slows down the heart rate, and improves the symptoms of heart failure. Digoxin can be used for conditions such as atrial fibrillation, heart failure, or congenital heart defects. However, digoxin has a narrow therapeutic range and requires careful monitoring of the blood levels and the patient's response.
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