A preterm newborn has been receiving orogastric feedings of breast milk. The nurse initiates nipple feedings, but the newborn tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention?

Correct Answer: C

Rationale: The most appropriate nursing intervention in this situation is to resume orogastric feedings of breast milk. The newborn is showing signs of fatigue and weak sucking and swallowing reflexes during nipple feedings, indicating that they may not be ready to tolerate full oral feedings yet. By resuming orogastric feedings of breast milk, the newborn can continue to receive nutrition while building strength and coordination for oral feedings. It is important to progress gradually and monitor the newborn's tolerance for oral feedings before attempting nipple feedings again.

Correct Answer: A

Rationale: In caring for a newborn receiving phototherapy, it is crucial to understand the rationale behind the interventions to ensure optimal outcomes for the infant. A) Avoid stimulation is an appropriate intervention because excessive handling or stimulation can increase the breakdown of bilirubin, which is what phototherapy aims to reduce. Minimizing stimulation helps to maximize the effectiveness of the treatment. B) Decreasing fluid intake is not appropriate in this situation. Maintaining adequate hydration is essential to help eliminate bilirubin from the body. Therefore, decreasing fluid intake could hinder the elimination process and potentially worsen the jaundice. C) Exposing all the newborn's skin is not necessary. The areas that need to be exposed to the phototherapy lights are typically the back and buttocks, as these areas have the highest surface area for effective light absorption. Exposing all the skin may lead to unnecessary heat loss and discomfort for the newborn. D) Monitoring skin temperature closely is not directly related to the care of a newborn receiving phototherapy. While monitoring the infant's overall temperature is important, the primary focus in phototherapy is to monitor bilirubin levels and the effectiveness of the treatment. In an educational context, understanding the rationale behind each intervention is vital for nurses caring for newborns receiving phototherapy. This knowledge ensures that appropriate and evidence-based care is provided to optimize the infant's health outcomes. It highlights the importance of individualized care and critical thinking in pediatric pharmacology practices.

Correct Answer: C

Rationale: The nurse should describe all details related to the chief complaint under the "Present illness" section of the health history. This section focuses specifically on the patient's current health problem, including the onset, duration, severity, aggravating or alleviating factors, and associated symptoms. It provides a comprehensive understanding of the chief complaint and helps guide further assessment and treatment interventions. The "Chief complaint" section typically contains a concise statement from the patient regarding the main reason for seeking healthcare.

Correct Answer: C

Rationale: Significant head lag in an 8-month-old infant can be a concerning sign indicating potential developmental delays or muscle weakness. The most appropriate action for the nurse in this situation is to refer the child for further evaluation by a healthcare provider, such as a pediatrician or developmental specialist, to assess and address the underlying cause of the head lag. It is important to rule out any potential developmental issues early on to provide the necessary interventions and support for the infant's optimal growth and development.

Correct Answer: B

Rationale: The nurse is testing the girl's cerebellar function by asking her to do the "finger-to-nose" test. The cerebellum is the part of the brain that plays a crucial role in coordinating movement, balance, and posture. In the finger-to-nose test, the child is asked to touch her own nose and then the nurse's finger repeatedly. A properly functioning cerebellum helps control and coordinate these precise movements. If there are issues with the cerebellar function, the child might have difficulty performing this task accurately, indicating a potential problem with motor coordination and balance.