What is a nurses primary critical observation when

54. What is a nurse’s primary critical observation when
performing an assessment for determining an
Apgar score?
a. Heart rate
b. Respiratory rate
c. Presence of meconium
d. Evaluation of Moro reflex
55. While a mother is inspecting her newborn she
expresses concern that her baby’s eyes are
crossed. How should the nurse respond?
SITUATION 12 – An infant with hypertrophic
pyloric stenosis (HPS) is admitted to the
pediatric unit.
56. What is most important for the nurse to assess?
57. What does the nurse expect when palpating the
infant’s abdomen?
58. Surgery to correct hypertrophic pyloric stenosis
(HPS) is performed on the infant who had been
formula-fed. Which postoperative feeding order is
appropriate?
a. Thickened formula 24 hours after surgery
b. Withholding feedings for the first 24 hours
c. Regular formula feeding within 24 hours after
surgery
d. Additional glucose feedings as desired after
first 24 hours
59. Corrective surgery for hypertrophic pyloric stenosis
(HPS) is completed, and the infant is returned to
the pediatric unit with an IV infusion in place. What
is the priority nursing action?
60. An infant had corrective surgery for hypertrophic
pyloric stenosis (HPS). What should the nurse teach
a parent to do immediately after a feeding to limit
vomiting?