what is the most appropriate nursing action when intermittently gavage feeding a preterm infant
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?

Correct answer: A

Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.

2. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

Correct answer: A

Rationale: Directly asking the adolescent if she is sexually active is the most straightforward and respectful approach, ensuring privacy and fostering trust.

3. An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age?

Correct answer: C

Rationale: By 5 months, an infant's weight should typically double from birth, and length should increase by approximately 50%.

4. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation?

Correct answer: C

Rationale: When caring for a child with probable appendicitis, sudden relief from pain is a critical sign that could indicate perforation of the appendix. Perforation results in the release of pressure and inflammation, leading to a temporary relief of pain. Anorexia (loss of appetite) and decreased abdominal distention are symptoms commonly associated with appendicitis itself, not perforation. Bradycardia (slow heart rate) is not typically a direct manifestation of appendicitis or its complications.

5. What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?

Correct answer: D

Rationale: Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as muscle cramps, tetany, or seizures. Other symptoms like nausea, vomiting, and weakness are less specific and can be related to various conditions.

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