A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn's cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.

Correct Answer: D

Rationale: Flushing the client's tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client's gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client's electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client's head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.

Correct Answer: A

Rationale: Corrected Rationale: Blurred vision is a common symptom of hypoglycemia and should be included in the teaching. Other manifestations like vomiting, Kussmaul respirations, and bradycardia are not typically associated with hypoglycemia. Vomiting is more commonly seen in conditions like food poisoning or gastrointestinal issues. Kussmaul respirations are deep and rapid respirations seen in metabolic acidosis, not hypoglycemia. Bradycardia is usually not a manifestation of hypoglycemia; tachycardia is more commonly associated with low blood sugar levels.

Correct Answer: A

Rationale: Corrected Rationale: Vitamin C deficiency can impair collagen synthesis and delay wound healing, making it crucial for recovery from pressure ulcers. Incorrect Rationales: - Vitamin D deficiency is associated with bone health, not specifically wound healing. - Vitamin E deficiency can lead to neurological and immune system issues but is not directly linked to delayed wound healing. - Vitamin B6 deficiency can cause skin rashes and neurological symptoms but is not a primary factor in delayed wound healing.

Correct Answer: B

Rationale: The correct answer is B. Maintaining an HbA1c level of 5 percent indicates good long-term blood glucose control and understanding of diabetes management. Choice A is incorrect because the presence of albumin in the urine (albuminuria) is actually an indication of kidney damage in diabetes. Choice C is incorrect as ketones in the urine are a sign of inadequate insulin and can occur when blood glucose levels are high, not at a specific level like 190 mg/dL. Choice D is also incorrect as the client should aim to keep blood glucose levels within a tighter range for better control, typically between 80-130 mg/dL before meals and less than 180 mg/dL after meals.