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Total bishops score is:
- A. 10
- B. 8
- C. 6
- D. 4
- E. 13
Correct Answer: E
Rationale: The Bishop score assesses cervical readiness for labor with a maximum of 13 points (dilation effacement station consistency position). Higher scores indicate better inducibility.
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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).
Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents call the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
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
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
Which statement by the nurse would best help the parents cope with their feelings?
- A. You'll feel better if you visited your child for shorter periods of time.
- B. Don't worry. You're doing a great job, and everything will work out for the best.
- C. This is painful for you. Let's identify things you can do to help make your child feel good.
- D. It's sad that you feel helpless. What do you usually do to take your mind off your worries?
Correct Answer: C
Rationale: Acknowledging the parents' pain and suggesting actionable ways to help their child empowers them, addressing helplessness constructively and fostering coping.