Nokea
A 3-month-old has pulled out their NG tube at home, and the mother is now speaking with the on-call nurse. What recommendation should the nurse provide her?
- A. drive the infant to the nearest ER
- B. Call 911 and wait for EMS to arrive
- C. attempt to replace the NG tube yourself following discharge training
- D. feed the infant by mouth as there is not an NG tube to use
Correct Answer: C
Rationale: The correct answer is C because the mother was trained on NG tube replacement. This knowledge ensures proper technique and reduces the risk of injury. Driving to the ER or calling 911 may waste time, and feeding by mouth without the NG tube is not safe. Replacing the NG tube at home is the most efficient and appropriate course of action in this scenario.
You may also like to solve these questions
Which infant is at greatest risk for developing hypoglycemia after birth?
- A. Severe small for gestational age infant
- B. Appropriate for gestational age infant
- C. Infant of a diabetic mother with maternal glucose control
- D. Cold-stressed term infant
Correct Answer: A
Rationale: The correct answer is A: Severe small for gestational age (SGA) infant, as they have limited glycogen stores and are at higher risk for hypoglycemia. SGA infants often have poor growth in utero, leading to decreased nutrient reserves. This puts them at increased risk for low blood sugar levels after birth.
Incorrect choices:
B: Appropriate for gestational age infants typically have adequate glycogen stores and are at lower risk for hypoglycemia.
C: Infants of diabetic mothers with good maternal glucose control are less likely to have hypoglycemia due to stable blood sugar levels in utero.
D: Cold-stressed term infants may have transient hypoglycemia, but they are not at the greatest risk compared to severe SGA infants.
Which intervention should the nurse instruct the parents to do for their newborn who has acute diaper rash?
- A. Apply the diaper loosely to infant, allowing for better air circulation.
- B. Change the newborn every 4 hours to prevent a moist environment.
- C. Wash the newborn’s diaper area with an antibacterial soap and newborn wipes.
- D. Wipe off the diaper cream thoroughly between diaper changes.
Correct Answer: A
Rationale: The correct answer is A: Apply the diaper loosely to infant, allowing for better air circulation. This is the best intervention for acute diaper rash as it helps reduce moisture and promotes healing. Tight diapers trap moisture, worsening the rash. Choice B is incorrect as changing every 2-3 hours is recommended to maintain a dry environment. Choice C is incorrect as antibacterial soap can be harsh and disrupt the skin's natural flora. Choice D is incorrect as wiping off diaper cream thoroughly can irritate the skin further.
The nurse is providing support to a mother whose newborn is diagnosed with a life-threatening defect. The mother states, “I just want to go home and never come back.” Which reaction by the mother does the nurse recognize?
- A. Guilty feelings by the mother
- B. Delay of attachment process
- C. Maternal emotional distancing
- D. Disruption of family life
Correct Answer: C
Rationale: The correct answer is C: Maternal emotional distancing. The mother's statement of wanting to go home and never come back indicates a desire to emotionally distance herself from the situation. This reaction is a common coping mechanism when faced with overwhelming emotions. Guilty feelings (choice A) typically involve a sense of responsibility or remorse, which is not evident in the mother's statement. Delay of attachment process (choice B) refers to difficulties in forming an emotional bond with the newborn, which is not explicitly mentioned in the scenario. Disruption of family life (choice D) implies changes in family dynamics, which are not directly related to the mother's expressed desire to distance herself emotionally.
Which clinical sign is most concerning immediately following the delivery of a high-risk neonate?
- A. Axillary temperature of 97.8°F
- B. Blood glucose of 35 g/dL
- C. Oxygen saturation of 90%
- D. Blue-tinged hands and feet
Correct Answer: B
Rationale: The correct answer is B: Blood glucose of 35 g/dL. This is the most concerning sign as hypoglycemia in neonates can lead to serious neurological complications. Low blood glucose levels can result in seizures, brain damage, and even death if not promptly addressed. It is crucial to maintain appropriate blood glucose levels in neonates to support their brain development and overall health.
Explanation of other choices:
A: Axillary temperature of 97.8°F - Slightly below normal but not immediately concerning.
C: Oxygen saturation of 90% - Suboptimal but not as critical as severe hypoglycemia.
D: Blue-tinged hands and feet - Could indicate poor circulation, but hypoglycemia is more urgent to address.
A family who immigrated to the United States in the past year is preparing to take their infant home with both oxygen and G-tube feeds. How does the nurse know discharge education has prepared them for success?
- A. The caregiver has been able to demonstrate a G-tube feed successfully at the correct feeding times throughout the day.
- B. The caregiver was unable to safely administer all medications at the prescribed times during the day and night.
- C. The family has cultural concerns that have not been addressed at this time regarding home-going care for the infant, but a social worker has been consulted.
- D. Oral feeding is important to the caregiver for the infant, and they continue to attempt PO feedings after both the nurse and attending physician have explained the infant’s need for G-tube feedings.
Correct Answer: A
Rationale: Step 1: Demonstrating successful G-tube feeds indicates understanding and ability to provide necessary nutrition to the infant.
Step 2: Correct feeding times show adherence to the prescribed schedule for optimal care.
Step 3: Successful demonstration implies comprehension of G-tube feed technique and importance of consistency.
Step 4: This knowledge ensures the infant receives proper nutrition and contributes to their overall well-being.
Summary: Choice A is correct as it demonstrates the family's readiness to provide essential care for the infant. Choices B, C, and D are incorrect as they do not address the core aspect of ensuring proper nutrition and care through successful G-tube feeds.