what is the most appropriate nursing action when intermittently gavage feeding a preterm infant
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?

Correct answer: A

Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.

2. The parent of an 8.2-kg (18-lb) 9-month-old infant is borrowing a federally approved car seat from the clinic. The nurse should explain that the safest way to put in the car seat is what?

Correct answer: B

Rationale: Infants should be placed rear-facing in the back seat until they are at least 2 years old or exceed the weight/height limit of their car seat for optimal safety.

3. Parents of a preschool child ask the nurse, "Should we set rules for our child as part of a discipline plan?" Which is an accurate response by the nurse?

Correct answer: D

Rationale: Clear and reasonable rules provide structure and help children understand expectations, promoting consistent behavior and discipline.

4. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

5. The LPN is caring for a 1-month-old patient post-surgery. Which pain scale is expected to be used to evaluate post-op pain?

Correct answer: C

Rationale: The FLACC (Face, Legs, Activity, Cry, Consolability) scale is commonly used to assess pain in infants and young children who are unable to verbally communicate their pain. This scale is particularly useful in assessing post-operative pain in infants as it evaluates different behaviors and physiological responses to pain. The Oucher scale is more commonly used with children who are older and can provide self-report of pain intensity. Wong-Baker FACES scale is primarily used with children who are older and can indicate their pain level by pointing to facial expressions. The 0-10 pain scale is typically used with older children and adults who can rate their pain on a numerical scale.

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