A nurse is caring for an infant receiving continuous positive airway pressure (CPAP) therapy and observes signs of nasal flaring and retractions. Which of the following is an appropriate nursing action?
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AInstill a bolus of sterile normal saline before adjusting the CPAP settings
BTurn the infant's head from side to side during CPAP interface adjustment
CProvide non-nutritive sucking with sucrose and swaddling during the adjustment of the CPAP interface
DIncrease the CPAP pressure without consulting the physician
✓ Correct answer: C. Provide non-nutritive sucking with sucrose and swaddling during the adjustment of the CPAP interfaceAnswer: Provide non-nutritive sucking with sucrose and swaddling during the adjustment of the CPAP interface Comfort measures (e.g., non-nutritive sucking, expressed breast milk, sucrose, and swaddling) are recommended during CPAP interface adjustments to provide pain relief and reduce stress responses. Increasing the CPAP pressure without consulting the physician can cause potential harm and is not recommended. Mucus is not miscible with saline solution, so a bolus of saline will not help in this situation. Additionally, bolus saline has no role in adjusting CPAP settings. Turning the infant's head during CPAP adjustment is not advised, as it could occlude the jugular vein, increase intracranial pressure, and pose other risks.
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