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Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life?
- A. Weak or absent sucking or swallowing reflex
- B. Inability to digest food properly
- C. Refusal to take formula by mouth
- D. Need for a larger quantity of formula at each feeding
Correct Answer: A
Rationale: When the preterm infant's sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.
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What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool?
- A. Assess for abdominal distention.
- B. Decrease the amount of the next feeding.
- C. Institute enteric precautions.
- D. Get a culture of the next stool.
Correct Answer: A
Rationale: Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.
Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents?
- A. To bring in colorful pictures and toys to place in the incubator
- B. That stimulating the infant during feedings increases intake
- C. To stroke the infant during feeding to increase intake
- D. Not to disturb the infant between feedings
Correct Answer: C
Rationale: During gavage feedings, stroking the infant gently can provide stimulation.
What term describes the age of a neonate that is based on the actual time in utero?
- A. Maturational age
- B. Gestational age
- C. Neurological age
- D. Chronological age
Correct Answer: B
Rationale: The gestational age is the age based on the actual time in the uterus.
The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation?
- A. Administer oxygen via a nasal cannula.
- B. Gently rub the infant's feet or back.
- C. Ventilate with an Ambu bag.
- D. Perform nasopharyngeal suctioning.
Correct Answer: B
Rationale: Gently rubbing the infant's back, ankles, or feet may stimulate the infant to breathe.
How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
- A. Check tube placement by injecting air into the stomach.
- B. Weigh the infant before the feeding.
- C. Aspirate stomach contents.
- D. Check serum glucose level.
Correct Answer: C
Rationale: When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.