The nurse is caring for a 4-year-old with cerebral palsy on an inpatient unit who is struggling to eat with regular utensils. What intervention will the nurse include in the plan of care?

Call the provider to request an enteral tube.

Provide large, padded utensils.

Have the parents feed the child.

Refer the patient to the nutritionist.

Answer and Explanation

The Correct Answer is B

Choice A reason: Requesting an enteral tube is not necessary unless the child is unable to eat orally at all. The goal is to support the child's ability to eat independently, if possible.

Choice B reason: Providing large, padded utensils can help a child with cerebral palsy improve their ability to eat independently. Adaptive utensils are designed to accommodate the motor challenges that children with cerebral palsy may face, making it easier for them to grasp and use the utensils.

Choice C reason: While having the parents feed the child can be a short-term solution, it does not promote independence. The focus should be on finding ways to support the child's ability to eat on their own.

Choice D reason: Referring the patient to a nutritionist can be helpful for overall dietary management, but it does not directly address the immediate issue of the child's difficulty with using regular utensils. Adaptive utensils are a more direct solution to this problem.

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Correct Answer is ["1"]

Explanation

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

A. An infant 6 hours old, 41 weeks and 5 days gestation. B. An infant 18 hours old, 36 weeks and 6 days gestation. C. An infant 34 hours old, 37 weeks and 3 days gestation. D. An infant 27 hours old, 38 weeks and 0 days gestation.

Correct Answer is B

Explanation

Choice A reason: A newborn at 41 weeks and 5 days gestation is past full term and, while being older in gestational age, does not typically present increased risk for feeding difficulties as compared to preterm infants. At 6 hours old, this infant would still be adapting, but no additional risk is posed by the gestational age.

Choice B reason: An infant born at 36 weeks and 6 days gestation is considered late preterm. Late preterm infants often have immature suck and swallow reflexes and may experience difficulties with feeding, coordinating breathing with feeding, and maintaining body temperature. These issues place them at a higher risk for feeding difficulties compared to full-term infants.

Choice C reason: A newborn at 37 weeks and 3 days gestation is considered early term and generally faces fewer risks compared to preterm infants. At 34 hours old, feeding patterns are still being established, but there are no significant additional risks related to their gestational age.

Choice D reason: An infant born at 38 weeks gestation is considered full term. At 27 hours old, the baby would still be in the early stages of adapting to feeding, but being full term generally implies a lower risk for feeding difficulties compared to preterm infants.

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The nurse is caring for a 4-year-old with cerebral palsy on an inpatient unit who is struggling to eat with regular utensils. What intervention will the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

The nurse is assessing newborn patients who are at risk for feeding difficulties. Which patient is at the highest risk?

Correct Answer is B

Explanation

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