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?

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Question 1 of 5

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.

Question 2 of 5

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? (Select all that apply.)

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

Where in the health history should the nurse describe all details related to the chief complaint?

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.

Question 4 of 5

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?

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.

Question 5 of 5

A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. What is the nurse testing for?

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.

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