The practical nurse (PN) is feeding a 2-month-old male infant with heart failure due to a ventricular septal defect (VSD). Which intervention should the PN implement?
Weigh before and after feeding.
Allow the infant to rest before feeding.
Feed the infant when he cries.
Insert a nasogastric feeding tube.
The Correct Answer is B
In infants with heart failure, they may have difficulty feeding due to fatigue and increased work of breathing. Allowing the infant to rest before feeding helps conserve their energy and reduces the risk of excessive fatigue during feeding.
The other options are not appropriate interventions for this situation:
A. Weigh before and after feeding: Weighing before and after feeding is not necessary in this case unless specifically ordered by the healthcare provider. It is not directly related to the management of feeding an infant with heart failure.
C. Feed the infant when he cries: Feeding the infant solely based on crying may not be appropriate in this case. It is important to establish a feeding schedule and monitor the infant's signs of hunger and satiety to ensure adequate nutrition and prevent overfeeding.
D. Insert a nasogastric feeding tube: Inserting a nasogastric feeding tube should not be the first intervention unless there is a specific indication or order from the healthcare provider. In this scenario, the focus is on supporting oral feeding and allowing the infant to rest before feeding.
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Related Questions
Correct Answer is C
Explanation
The client's complaint of a leg cramp suggests the possibility of a muscle cramp or spasm, which is a common occurrence during labor. Extending the leg and flexing the foot helps stretch and relax the affected muscle, which can alleviate the cramp. This intervention helps relieve the muscle spasm and promotes increased blood circulation to the area, potentially reducing the intensity and duration of the cramp.
A. Elevating the leg above the heart is not necessary for relieving a leg cramp. It may be helpful in certain situations, such as in the case of venous insufficiency or swelling, but it is not the First-line intervention for a leg cramp.
B. Massaging the calf and foot can be beneficial in relieving a leg cramp. However, the initial action should be to extend the leg and flex the foot to actively stretch the affected muscle. If the cramp persists or if additional comfort measures are needed, then the PN may consider massaging the calf and foot.
D. Checking the pedal pulse in the affected leg is not directly related to relieving a leg cramp. It may be a relevant assessment in certain situations, such as suspected circulatory compromise or deep vein thrombosis, but it is not the primary intervention for a leg cramp.
Correct Answer is D
Explanation
Choice A reason:
Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.
Choice B reason:
Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.
Choice C reason:
Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.
Choice D reason:
Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.
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