The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a special feeding device that has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. Which instructions should the nurse provide the mother about feedings?

Squeeze the nipple base to introduce milk into the mouth.

Position the baby in the left lateral position after feeding.

Alternate milk with water during the feeding.

Hold the newborn in an upright position.

Answer and Explanation

The Correct Answer is D

A. Squeeze the nipple base to introduce milk into the mouth: This may increase the risk of aspiration if milk flows too rapidly, especially in infants with cleft lips who have difficulty forming a tight seal and managing suck-swallow coordination effectively.

B. Position the baby in the left lateral position after feeding: Although side-lying may aid digestion in some cases, it’s not the priority after feeding a newborn with cleft lip. Upright positioning is safer and helps reduce aspiration risk.

C. Alternate milk with water during the feeding: Offering water during feedings is not recommended for newborns, as it can displace nutritional intake and may disrupt electrolyte balance. It also offers no benefit for cleft lip management.

D. Hold the newborn in an upright position: This reduces the risk of aspiration by improving control of milk flow and promoting effective swallowing. It is the safest and most effective position for feeding an infant with cleft lip.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.

B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.

C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.

D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.

A. Palpate and compare radial pulses. B. Administer ondansetron 4 mg IV. C. Perform range of motion. D. Check capillary refill on bilateral upper extremities. E. Inspect the bandage for drainage. F. Provide morphine 2 mg IV push (IVP).

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.

Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Correct Answer is C

Explanation

Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The diabetic nurse educator instructs the client to perform fingerstick blood glucose (FSBG) monitoring dropdownanddropdown.

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?

Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.