A neonate is fed 20 mL of formula every three hours by orogastric lavage. At the beginning of this feeding, the nurse aspirates 15 mL of gastric residual. Which action by the nurse is the most appropriate?

Correct Answer: A

Rationale: The correct answer is A: Withhold the feeding and notify the healthcare provider. The rationale for this is that aspirating 15 mL of gastric residual indicates delayed gastric emptying or potential risk of aspiration. Withholding the feeding and informing the healthcare provider allows for further assessment and potential interventions to prevent complications. Choice B is incorrect because replacing the residual and continuing with the full feeding may increase the risk of aspiration or other complications. Choice C is incorrect as giving only 5 mL of the feeding does not address the underlying issue of delayed gastric emptying. Choice D is incorrect as waiting three hours to check the residual without taking immediate action may lead to further complications if the issue persists.

Correct Answer: D

Rationale: The correct answer is D because a 2-lb weight gain in 12 months could indicate a potential health concern such as obesity or an underlying medical condition. This finding warrants further investigation by healthcare professionals to assess the child's overall health and well-being. A, B, and C are incorrect choices as they are typical developmental milestones for preschoolers. Independence in dressing, riding a tricycle, and having an imaginary friend are all considered normal behaviors at this age and do not necessarily indicate a need for further investigation unless there are other concerning factors present.

Correct Answer: B

Rationale: The correct answer is B: Record data on nurses’ notes. In this case, the infant's apical pulse of 166 beats/min is within the normal range for a 6-month-old during sleep. By recording this data on the nurses' notes, it ensures accurate documentation for future reference and monitoring. Administering oxygen (choice A) is not indicated as the pulse rate is normal. Reporting the data to the practitioner (choice C) is not necessary since the pulse rate is within the normal range. Placing the child in high Fowler position (choice D) is unrelated to the situation and not indicated based on the information provided.

Correct Answer: A

Rationale: The correct answer is A: Report findings to practitioner. A temperature of 38.4°C post-cardiac surgery may indicate infection, which requires prompt attention. Reporting to the practitioner allows for timely assessment and intervention. Choice B is incorrect as hypothermia blankets are used for low temperatures. Choice C is incorrect as it may exacerbate the fever. Choice D is incorrect as action is needed beyond just recording the temperature.

Correct Answer: C

Rationale: The correct answer is C: Circulatory stasis can lead to thrombus and embolus formation. Immobilization in children can lead to decreased muscle activity and venous return, increasing the risk of blood clots forming in the veins (thrombus) due to stagnant blood flow. These clots can dislodge and travel to the lungs causing a pulmonary embolism. Choices A, B, and D are incorrect because immobilization typically leads to a decrease in metabolic rate, worsens venous return due to lack of movement, and can result in bone demineralization rather than an increase in bone calcium.