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The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant’s stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant’s head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
Correct Answer: D, A, F, C, E, B, G
Rationale: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).
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If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
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Which of the following findings during a routine wellness checkup best indicates that a child has iron deficiency anemia?
- A. Weight gain and hypertension
- B. Nervousness and diarrhea
- C. Nausea and vomiting
- D. Pallor and listlessness
Correct Answer: D
Rationale: Pallor and listlessness are hallmark signs of iron deficiency anemia due to reduced hemoglobin, leading to decreased oxygen delivery and fatigue.
A 30 years old G5P4 is admitted in labor room with H/O 32 weeks gestation,mild vaginal bleeding and abdominal pain. O/E her blood pressure 140/100 mm Hg abdomen is tense tender and hard. Fetal heart sounds are not audible. What is the most likely diagnosis:
- A. Placenta praevia.
- B. Abruptio placenta.
- C. Preterm labour.
- D. Urinary tract infection.
- E. Vasa praevia.
Correct Answer: B
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Vaginal examination is contraindicated in pregnancy in which situation:
- A. Carcinoma of cervix.
- B. Gonorrhoea.
- C. Prolapsed cord.
- D. Placenta previa.
- E. Active labour.
Correct Answer: D
Rationale: Placenta previa contraindicates vaginal examination due to the risk of provoking severe hemorrhage. Other conditions may require caution but are not absolute contraindications.
Which instruction is essential to give the parents before the child's discharge?
- A. Return the child for a follow-up visit in 3 to 5 days.
- B. Give the child nothing by mouth for the next 12 hours.
- C. Check the child's pupillary response every 4 hours.
- D. Awaken the child every 4 hours during the first night.
Correct Answer: D
Rationale: Awakening the child every 4 hours during the first night allows monitoring for neurological deterioration, such as altered consciousness, critical after a head injury.