Nokea
The nurse evaluates a preterm infant after a gavage feeding. The nurse determines that feeding intolerance has developed when which finding is noted during assessment?
- A. The infant immediately falls asleep after feeding.
- B. The gastric residual is zero prior to the next feeding.
- C. The infant’s abdominal girth has increased in size.
- D. The infant is having soft,loose stools.
Correct Answer: C
Rationale: Increased abdominal girth indicates feeding intolerance suggesting issues like paralytic ileus or NEC. Sleeping zero residual and loose stools are normal.
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If the parents report all the following history findings to the nurse, which one is most closely correlated with an increased risk of rheumatic fever?
- A. The child was exposed to measles within the past 4 weeks.
- B. The child had a severe sore throat within the past 2 weeks.
- C. The child is lethargic and no longer interested in schoolwork.
- D. The child received a bump on the head while playing.
Correct Answer: B
Rationale: Rheumatic fever is strongly associated with a recent streptococcal infection, such as a sore throat caused by group A Streptococcus. A severe sore throat within the past 2 weeks is a key risk factor, as it may indicate an untreated or inadequately treated streptococcal infection.
The nurse has provided the mother with information about her newborn’s milia. The nurse evaluates that the mother understands information when the mother makes which statement?
- A. “I will put lotion on my infant’s nose in the morning and at night.”
- B. “I understand these raised white spots will clear up without treatment.”
- C. “I realize the baby will need surgery to remove these skin lesions.”
- D. “I will apply alcohol twice a day to the lesions until they disappear.”
Correct Answer: B
Rationale: Milia are benign self-resolving white spots from sebaceous glands clearing within a month. Lotion surgery or alcohol are inappropriate.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
A 25 years old P2 comes to emergency,after home delivery with heavy bleeding per vaginum. After evaluation and emergency resuscitation she is diagnosed as a case of uterine atony. What is the appropriate medicine in the management of this case:
- A. Oxytocin.
- B. Salbutamol.
- C. Beta blockers.
- D. Magnesium sulphate.
- E. Hydralazine.
Correct Answer: A
Rationale: Oxytocin is the first-line treatment for uterine atony as it stimulates uterine contractions to control postpartum hemorrhage. Other options are not indicated for this condition.