Before administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?a. Returning the aspirate and withholding the feedingb. Discarding the aspirate and administering the full feedingc. Returning the aspirate and subtracting the amount of the aspirate from the feedingd. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

1. Before administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?

a. Returning the aspirate and withholding the feeding

b. Discarding the aspirate and administering the full feeding

c. Returning the aspirate and subtracting the amount of the aspirate from the feeding

d. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

120

Acyclovir is used to treat herpes virus infection in a neonate. A high dose of 60 mg/kg/day of acyclovir reduces the mortality rate in children. The neonate has a birth weight of 4.4 lbs or 2 kg [2.2 lbs = 1 kg]; therefore, the nurse should administer 2 × 60 = 120 mg of acyclovir per day to the neonate
A!

Alterations in oxygen saturation can provide information about impending complications, permitting early intervention. Although a low oxygen saturation may be altered in the presence of pain, it is not the most specific way to determine whether a client is experiencing pain. The nurse still should obtain the oxygen saturation level when performing an assessment of a client in the home. Nonprofessionals do not have the expertise to alter ventilator settings. Ventilator settings should be maintained as prescribed by the health care provider.
C!

The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

D!

Answer D is the lower-lateral chest, which is the area of greatest thoracic excursion. With visceral and parietal pleural inflammation (pleurisy), a low-pitched, coarse, grating sound is heard when the client breathes, particularly when approaching the height of inspiration. Bronchial breath sounds are heard over the trachea and at the nape of the neck on either side of the vertebrae. Bronchial sounds are loud, high pitched, and hollow, with a short inspiratory phase and long expiratory phase. Bronchovesicular breath sounds are heard on either side of the sternum or between the scapulae; bronchovesicular sounds have a moderate volume and medium pitch, with equal inspiratory and expiratory phases. C is the area where vesicular breath sounds are heard. Vesicular sounds are soft and low pitched, with a long inspiratory phase and a short expiratory phase; they are heard over most lung fields.