The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?
Hold the infant with head and shoulders slightly elevated.
Use the syringe plunger to push formula at a rate of 5 ml/minute.
Microwave refrigerated formula to room temperature.
Measure and discard residual gastric contents before feeding.
The Correct Answer is A
Choice A reason: Holding the infant with head and shoulders slightly elevated helps prevent aspiration during feeding.
Choice B reason: Using the syringe plunger to push formula can increase the risk of aspiration and is not recommended.
Choice C reason: Microwaving formula can create hot spots and is not a safe method to warm formula.
Choice D reason: Measuring and discarding residual gastric contents is not typically recommended for routine feeding and can lead to improper assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering normal saline solution alone will not address the severe anemia caused by the low hemoglobin level.
Choice B reason: Obtaining additional consent is necessary, but it is not the immediate action required in this emergency situation.
Choice C reason: Rechecking the client's hemoglobin, blood type, and Rh factor is important, but the immediate priority is to address the severe anemia.
Choice D reason: Transfusing Type A negative blood is appropriate because it is compatible with AB negative blood and is necessary to treat the client's critical anemia.
Correct Answer is C
Explanation
Choice A reason: Ear pain and fever are not specific symptoms of mononucleosis and may indicate other infections such as otitis media.
Choice B reason: Elevated WBC (white blood cell) count and sedimentation rate can be seen in many infections and inflammatory conditions, but they are not specifically diagnostic of mononucleosis.
Choice C reason: Mononucleosis, often caused by the Epstein-Barr virus (EBV), typically presents with a positive EBV test and malaise (general feeling of discomfort or illness). Other common symptoms include fever, sore throat, swollen lymph nodes, and fatigue.
Choice D reason: Increased BUN (blood urea nitrogen) and serum creatinine levels are indicators of kidney function and are not typically associated with mononucleosis.
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