30 maternal-child nursing items that did not make it onto the site, across 5 sub-sections. Each is shown with the objection that killed it, verbatim.
Read this first
The questions on this page are flawed on purpose. The keyed answers and the reasoning behind them are wrong or unsafe in the way each objection describes. Do not memorise anything here as fact. The verified bank is on the practice pages.
Rejected — do not study this as correctGynecology
The nurse is providing education to a 34-year-old woman with heavy menstrual bleeding and pelvic pressure. Pelvic ultrasound reveals multiple intramural fibroids, the largest measuring 5 cm. The patient expresses a strong desire for future pregnancy. Which of the following interventions should the nurse anticipate the health care provider will recommend?
AHysterectomy
BMyomectomyKeyed by the writer
CUterine artery embolization
DOral tranexamic acid
What the audit caught
Option D rationale implies tranexamic acid is inappropriate specifically due to the patient's desire for pregnancy ('not definitive management for a patient desiring pregnancy'); however, tranexamic acid is safe for use while attempting conception and is excluded here primarily because it fails to address the 'pelvic pressure' (bulk symptoms) cited in the stem, not because of fertility goals.
Rejected — do not study this as correctGynecology
A 28-year-old woman presents for a routine gynecologic examination. She reports regular menstrual cycles and denies pelvic pain, bloating, or abnormal bleeding. A transvaginal ultrasound reveals a 3 cm anechoic, thin-walled cyst on the right ovary without septations or solid components. What is the most appropriate management?
ARefer for laparoscopic cystectomy
BReassure the patient; no further imaging is requiredKeyed by the writer
CPrescribe combined oral contraceptives for 3 months
DOrder a serum CA-125 level
What the audit caught
Scope of Practice Cues: Options A ('Refer'), C ('Prescribe'), and D ('Order') describe actions outside the scope of practice for a Registered Nurse (implied by 'Maternal-Child Nursing' competency without 'Advanced Practice' specification), while Option B ('Reassure') is within nursing scope. This allows test-wise elimination without clinical knowledge of ovarian cyst guidelines.
Rejected — do not study this as correctGynecology
A 58-year-old woman presents to a women's health nurse practitioner for a routine annual examination. She has been postmenopausal for 8 years and is asymptomatic. Bimanual examination reveals a 4-cm mobile, cystic right adnexal mass. Which of the following is the most appropriate next step in management?
ACT scan of the abdomen and pelvis
BTransvaginal ultrasound and serum CA-125 measurementKeyed by the writer
CDiagnostic laparoscopy with ovarian biopsy
DRepeat pelvic examination in 6 weeks
What the audit caught
Guideline nuance: While ACOG Practice Bulletin 174 supports concurrent CA-125, emerging value-based care guidelines suggest triaging with transvaginal ultrasound first to avoid unnecessary CA-125 testing in simple cysts <10 cm, making the 'always order both' approach potentially controversial depending on the specific board's adherence to cost-effectiveness updates.
Rejected — do not study this as correctGynecology
A 28-year-old woman, gravida 2 para 1, presents to the emergency department with a 2-day history of left lower quadrant pain and light vaginal spotting. Her last menstrual period was 6 weeks ago. She is hemodynamically stable. A urine pregnancy test is positive. Transvaginal ultrasound reveals an empty uterus and a 2.5 cm complex left adnexal mass with no fetal cardiac activity. Serum beta-hCG is 2,500 mIU/mL. She is Rh-positive, and her complete blood count, liver function tests, and renal function tests are within normal limits. Which of the following is the most appropriate next step in management?
ARepeat serum beta-hCG measurement in 48 hours
BPrepare the patient for diagnostic laparoscopy
CAdminister intramuscular methotrexate as prescribedKeyed by the writer
DPrepare the patient for dilation and curettage
What the audit caught
Option A Rationale: States 'an adnexal mass is visualized, confirming ectopic pregnancy.' A complex adnexal mass alone does not definitively confirm ectopic pregnancy (could be corpus luteum); definitive diagnosis requires an extrauterine gestational sac or mass separate from the ovary. While highly suggestive, 'confirming' is factually absolute.
Rejected — do not study this as correctGynecology
A 28-year-old woman presents with progressively worsening pelvic pain during menstruation over the past 2 years. She also reports deep dyspareunia and has been unable to conceive after 12 months of regular unprotected intercourse. Her menstrual cycles are regular, and she has no abnormal vaginal discharge or fever. Pelvic examination reveals a fixed, retroverted uterus and tender nodularity along the uterosacral ligaments. Which nursing action is most appropriate?
ANotify the healthcare provider of the findings and facilitate further evaluation.Keyed by the writer
BInstruct the patient to take over-the-counter ibuprofen for pain relief.
CAdvise the patient to apply a heating pad to the lower abdomen.
DTeach the patient about the benefits of regular exercise for dysmenorrhea.
What the audit caught
Test-Wiseness Cue: Option A is the only choice involving collaboration with a provider ('Notify the healthcare provider'), while B, C, and D are independent nursing interventions. Test-takers can identify the correct answer by recognizing that a pathological finding requires provider involvement, without knowing specific endometriosis signs.
Rejected — do not study this as correctGynecology
A 22-year-old sexually active woman presents with a 3-day history of lower abdominal pain, dyspareunia, and abnormal vaginal discharge. She is afebrile. Pelvic examination reveals bilateral adnexal tenderness and cervical motion tenderness. A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?
ACollect endocervical specimens for NAAT to guide antibiotic selection.
BAdminister prescribed empiric broad-spectrum antibiotics for pelvic inflammatory disease.Keyed by the writer
CPrepare the patient for transvaginal ultrasound to evaluate for tubo-ovarian abscess.
DPrepare the patient for diagnostic laparoscopy to confirm pelvic inflammatory disease.
What the audit caught
Scope of Practice Assumption: The stem describes assessment findings but does not state that a healthcare provider has evaluated the patient or written an order. Option B ('Administer prescribed...') assumes an order exists, which violates nursing scope of practice principles often tested in board exams (notify provider vs. implement order).
Rejected — do not study this as correctMaternity nursing
A 26-year-old primigravida at 34 weeks' gestation reports a sudden gush of clear fluid from the vagina. She denies contractions. The nurse performs a nitrazine test, which turns blue. Which action should the nurse avoid?
APerform a sterile speculum examination
BInitiate continuous electronic fetal monitoring
CAdminister prophylactic antibiotics as prescribed
DPerform a digital cervical examinationKeyed by the writer
What the audit caught
Option C uses the term 'Prophylactic antibiotics... for PPROM', which clinically refers to the latency antibiotic regimen (ampicillin/erythromycin) used to prolong pregnancy. This regimen is NOT indicated at 34 weeks per ACOG guidelines (delivery is indicated). While the rationale clarifies GBS prophylaxis, the option text creates ambiguity for students distinguishing between latency antibiotics (avoid at 34 weeks) and intrapartum GBS prophylaxis (indicated), potentially making Option C defensibly 'avoidable' depending on interpretation.
Rejected — do not study this as correctMaternity nursing
A 28-year-old G2P1 at 30 weeks gestation is admitted with regular contractions and cervical dilation of 2 cm. The provider orders nifedipine 20 mg orally every 6 hours for tocolysis. Which assessment finding is most important for the nurse to report?
AMaternal heart rate 110/min
BPatient reports headache and facial flushing
CMaternal blood pressure 88/50 mm HgKeyed by the writer
DRespiratory rate 18/min
What the audit caught
Rationale C relies on a rigid systolic blood pressure threshold of 90 mm Hg to define compromised uteroplacental perfusion. In pregnancy, systemic vascular resistance decreases, and baseline blood pressures are often lower; current evidence-based practice prioritizes reporting symptomatic hypotension (dizziness, oliguria) or significant deviation from baseline rather than an absolute numeric cutoff that may be physiologic for a gravid patient.
Rejected — do not study this as correctMaternity nursing
A 28-year-old G1P0 at 35 weeks gestation is admitted with preeclampsia with severe features. Her blood pressure is 170/110 mm Hg, and she has 3+ proteinuria. Which assessment finding should the nurse report immediately?
ABrisk deep tendon reflexes
BAnkle clonusKeyed by the writer
CMild epigastric discomfort
DFacial edema
What the audit caught
Stem reliance on 'Mild' qualifier: While 'Mild' distinguishes Option C from Option B, relying on subjective qualifiers for critical symptoms (epigastric pain in preeclampsia is always high-risk) introduces potential ambiguity. Any epigastric pain in this context warrants immediate attention, making the prioritization over clonus dependent on the word 'Mild' rather than distinct pathophysiology.
Rejected — do not study this as correctMaternity nursing
A 28-year-old gravida 2, para 1 at 35 weeks' gestation arrives at the labor and delivery unit with sudden onset of severe, constant abdominal pain and dark red vaginal bleeding. The uterus is firm and tender. Fetal heart rate is 90 bpm with minimal variability. The provider has been notified and is en route. What is the priority nursing action?
AAdminister oxygen at 10 L/min via non-rebreather mask.
BPrepare the client for emergency cesarean birth.Keyed by the writer
CInsert an indwelling urinary catheter.
DContinue external fetal monitoring.
What the audit caught
Option A rationale cites ACOG (physician guideline) to definitively rule out oxygen; AWHONN nursing guidelines still list maternal oxygen as a potential intrauterine resuscitation intervention despite limited evidence. Marking it 'false' based solely on ACOG may conflict with nursing curricula; rationale should emphasize it is not the priority over delivery preparation rather than unsupported.
Rejected — do not study this as correctMaternity nursing
A 28-year-old primigravida at 30 weeks gestation arrives at the labor unit with regular uterine contractions every 5 minutes and cervical dilation of 2 cm. The nurse explains to the patient that the prescribed betamethasone is given to:
AReduce the frequency of uterine contractions.
BHelp the baby's lungs develop.Keyed by the writer
CPrevent maternal infection.
DPrevent low blood sugar in the baby after birth.
What the audit caught
Rationale B states betamethasone reduces respiratory distress syndrome (RDS) risk up to 36 6/7 weeks; while steroids are used in late preterm (34-37 weeks), the primary indication for RDS prevention via surfactant-mediated lung maturity is 24-34 weeks, whereas late preterm use targets broader respiratory morbidity (e.g., transient tachypnea).
Rejected — do not study this as correctMaternity nursing
A 30-year-old primigravida at 36 weeks gestation arrives at the labor and delivery unit with sudden onset of painless, bright red vaginal bleeding. She denies contractions, and her vital signs are stable. What is the priority nursing action?
APerform a sterile vaginal examination and assess cervical dilation.
BInitiate continuous fetal monitoring and establish large-bore IV access.Keyed by the writer
CAdminister oxytocin and encourage ambulation to control bleeding.
DEncourage ambulation and provide oral fluids to promote labor.
What the audit caught
Option D rationale states ambulation is contraindicated to 'avoid cervical stimulation.' Ambulation does not cause cervical stimulation; cervical stimulation is caused by digital examinations, intercourse, or prostaglandins. Ambulation is contraindicated to minimize bleeding risk via gravity and prepare for potential emergency surgery.
Rejected — do not study this as correctNeonatal nursing
A nurse is caring for a 12-hour-old term newborn whose mother had prolonged rupture of membranes for 22 hours before delivery. The newborn is lethargic, has a temperature of 38.2°C (100.8°F), and a respiratory rate of 70 breaths/min. What is the nurse's priority action?
AAdminister an antipyretic as prescribed.
BNotify the healthcare provider of the findings.Keyed by the writer
CObtain a blood culture and start intravenous antibiotics.
DPerform a thorough head-to-toe physical assessment.
What the audit caught
Option A Rationale: The statement that antipyretics are 'generally avoided in neonates due to immature hepatic metabolism' is clinically imprecise. Acetaminophen is commonly and safely used in term neonates for pain and PDA management when dosed appropriately. The primary reason to avoid antipyretics in this specific scenario is to prevent masking the fever curve during a sepsis workup, not solely due to inherent toxicity or metabolic contraindication.
Rejected — do not study this as correctNeonatal nursing
A term newborn is 12 hours old. The mother had prolonged rupture of membranes for 22 hours before delivery. The nurse has ensured a neutral thermal environment, but the newborn's axillary temperature is 37.8°C (100.0°F), and he is lethargic with a weak suck and poor feeding. Which action should the nurse take first?
AAdminister intravenous antibiotic therapy.
BNotify the healthcare provider of the assessment findings.Keyed by the writer
CObtain a blood culture for laboratory analysis.
DPerform a complete head-to-toe physical assessment.
What the audit caught
Clinical Gap: Lethargy and poor suck in a 12-hour old newborn are hallmark signs of hypoglycemia, a condition nurses can assess and treat independently. The option set lacks 'Check blood glucose,' forcing the nurse to notify the provider before ruling out a reversible, nursing-manageable cause. Best practice dictates assessing glucose prior to notification unless respiratory/cardiac arrest is present.
Rejected — do not study this as correctNeonatal nursing
A nurse is assessing a 36-hour-old newborn who was exposed to methadone in utero. The newborn is jittery, has a high-pitched cry, and is difficult to console. Which action should the nurse take first?
AAdminister morphine as prescribed.
BInitiate neonatal abstinence syndrome scoring.
CSwaddle the infant and reduce environmental stimuli.Keyed by the writer
DNotify the healthcare provider of the findings.
What the audit caught
Rationale B clinical precision: The rationale states scoring is performed on a 'calmer infant' after comfort measures; however, certain scoring tools (e.g., Finnegan) require observation of specific withdrawal signs (tremors, irritability) that may be masked by swaddling, though ESC focuses on consolability. The rationale oversimplifies the assessment-intervention relationship.
Rejected — do not study this as correctNeonatal nursing
A 2-day-old term newborn is brought to the nursery with maternal concern that the baby is 'not acting right.' The mother had prolonged rupture of membranes for 22 hours before delivery. The nurse notes the newborn is lethargic, has a weak suck, and an axillary temperature of 38.2°C (100.8°F). What is the priority nursing action?
AAdminister acetaminophen as prescribed for the fever.
BObtain a blood glucose level to rule out hypoglycemia.
CNotify the provider and prepare for a sepsis evaluation.Keyed by the writer
DApply a cool compress to the newborn's forehead.
What the audit caught
Teaching Point contains outdated/controversial guidance: Stating axillary temperature is 'preferred... due to safety concerns with rectal thermometry' contradicts many current neonatal sepsis guidelines (e.g., AAP) which consider rectal temperature the gold standard for core temperature accuracy in suspected sepsis, as axillary readings may miss significant fever.
Rejected — do not study this as correctNeonatal nursing
A nurse is assessing a 3-day-old term newborn who is breastfeeding. The infant has jaundice visible to the chest, is alert, and has normal vital signs. The total serum bilirubin is 12 mg/dL (205 µmol/L). Which type of jaundice does the nurse suspect?
APathologic jaundice due to ABO incompatibility
BPhysiologic jaundiceKeyed by the writer
CBreast milk jaundice
DJaundice due to biliary atresia
What the audit caught
Stem specifies 'breastfeeding' at day 3, which clinically raises suspicion for 'Breastfeeding Jaundice' (insufficient intake) distinct from 'Physiologic Jaundice' (enzymatic immaturity); while the infant's stability supports Physiologic, the absence of weight loss data creates slight ambiguity between early breastfeeding jaundice and physiologic jaundice.
Rejected — do not study this as correctNeonatal nursing
A nurse is preparing to administer intravenous ampicillin and gentamicin to a 2-hour-old term newborn with risk factors for early-onset sepsis, including maternal chorioamnionitis. Which action is most important for the nurse to take before administering the antibiotics?
AVerify the newborn's identification band.
BObtain blood cultures as prescribed.Keyed by the writer
CCheck the newborn's blood glucose level.
DConfirm patency of the intravenous line.
What the audit caught
Option A (Verify ID) represents a National Patient Safety Goal (NPSG.01.01.01) that universally precedes all medication administrations. Prioritizing diagnostic protocol (Option B) over fundamental patient safety creates a hierarchy ambiguity; in strict nursing safety frameworks, preventing wrong-patient administration supersedes diagnostic accuracy.
Rejected — do not study this as correctPediatric medical
A 7-year-old child is admitted with periorbital edema, tea-colored urine, and a blood pressure of 140/90 mm Hg obtained with a standard adult-sized cuff. The parent reports the child had a sore throat 2 weeks ago. Which nursing action is the priority?
AAdminister the prescribed diuretic immediately.
BAssess the child for headache, vomiting, and visual changes.Keyed by the writer
CEncourage increased oral fluid intake to maintain hydration.
DPrepare the child for emergency dialysis.
What the audit caught
The stem explicitly states the blood pressure was obtained with an 'adult-sized cuff' on a 7-year-old, which renders the data invalid (too large cuff yields falsely low reading). Per nursing standards and AAP guidelines, the priority action for an abnormal vital sign obtained with incorrect equipment is to validate the data by rechecking with the correct cuff size. This correct action is not offered as a standalone option.
Rejected — do not study this as correctPediatric medical
A 6-year-old boy with a history of asthma presents to the emergency department with increased work of breathing. He is tachypneic, using accessory muscles, and has diffuse expiratory wheezing. His oxygen saturation is 94% on room air. Which of the following is the priority intervention?
AObtain a peak expiratory flow measurement to assess severity
BAdminister inhaled albuterol via metered-dose inhaler with spacerKeyed by the writer
CAdminister oral prednisolone to reduce inflammation
DStart oxygen therapy via nasal cannula at 2 L/min
What the audit caught
Option B creates ambiguity regarding delivery method: While evidence supports MDI+spacer for mild-moderate exacerbations, the presence of 'accessory muscle use' often triggers ED protocols for nebulized SABA to ensure delivery during significant respiratory distress, making this option contestable for candidates familiar with acute care protocols versus strict guideline evidence.
Rejected — do not study this as correctPediatric medical
A 4-year-old child is brought to the emergency department with a 4-hour history of high fever, irritability, and a new petechial rash on the trunk and extremities. The child is crying and resists neck flexion. The nurse suspects meningococcal meningitis. What is the priority nursing action?
AAdminister acetaminophen as prescribed for fever and discomfort.
BPlace the child on droplet precautions immediately.Keyed by the writer
CPrepare the child for a lumbar puncture to confirm the diagnosis.
DStart intravenous antibiotics as soon as possible.
What the audit caught
Rationale for Option D states antibiotics can be given 'after which' isolation is initiated, implying a sequential delay that contradicts current sepsis/meningitis bundles requiring antibiotics within 1 hour without unnecessary delay; isolation (masking) should be concurrent with preparation for antibiotics, not a prerequisite that delays treatment.
Rejected — do not study this as correctPediatric medical
A 6-month-old infant is admitted to the pediatric unit with a diagnosis of acute bronchiolitis. The nurse notes nasal flaring, intercostal retractions, and an oxygen saturation of 88% on room air. What is the priority nursing action?
AAdminister albuterol nebulization as prescribed.
BInitiate supplemental oxygen to maintain saturation at or above 90%.Keyed by the writer
CPerform nasopharyngeal suctioning to clear secretions.
DAdminister oral corticosteroids as prescribed.
What the audit caught
Fatal ambiguity between Nursing ABC hierarchy and Medical Guidelines: Standard nursing fundamentals prioritize Airway (suctioning) before Breathing (oxygen), especially in obligate nose breathers with secretions, while AAP guidelines prioritize oxygen thresholds. This creates two defensibly correct answers (B and C) depending on the framework used.
Rejected — do not study this as correctPediatric medical
A 3-year-old child presents with a 5-day history of high fever (39.2°C), bilateral non-purulent conjunctival injection, an erythematous maculopapular rash on the trunk, swollen hands and feet, and a strawberry tongue. The nurse suspects Kawasaki disease. Which intervention is the priority to prevent the most serious complication of this condition?
AAdminister intravenous antibiotics as prescribed.
BAdminister intravenous immunoglobulin as prescribed.Keyed by the writer
CObtain an urgent echocardiogram to assess coronary arteries.
DAdminister oral corticosteroids as prescribed.
What the audit caught
Option B rationale specifies 'Low-dose aspirin,' which aligns with current AHA 2017 guidelines (3-5 mg/kg/day), but older protocols often distinguished high-dose acute vs. low-dose subacute; while currently accurate, clarity on 'anti-inflammatory vs anti-platelet' dosing phases could be improved to avoid confusion with outdated curricula.
Rejected — do not study this as correctPediatric medical
A 4-year-old child is admitted with a 6-day history of high fever (39.5°C), bilateral conjunctival injection without exudate, cracked red lips, a strawberry tongue, and a polymorphous rash on the trunk. The nurse suspects Kawasaki disease. Which intervention should the nurse anticipate as the priority?
AAdminister low-dose aspirin as prescribed
BAdminister intravenous immunoglobulin (IVIG) therapyKeyed by the writer
CObtain blood cultures from two different sites
DApply topical emollients to the skin rash
What the audit caught
Option A rationale states low-dose aspirin is used for 'anti-inflammatory and antiplatelet effects'; clinically, low-dose aspirin (3-5 mg/kg/day) provides antiplatelet effects only, while anti-inflammatory effects were associated with historical high-dose regimens which are no longer routinely recommended per AHA 2017 guidelines.
Rejected — do not study this as correctPediatric surgical
A 4-month-old infant with Hirschsprung disease is admitted for a pull-through procedure. The nurse notes sudden onset of abdominal distension, foul-smelling watery stools, and a temperature of 38.5°C. Which action should the nurse take first?
AAdminister the prescribed antipyretic.
BNotify the surgeon immediately.Keyed by the writer
CIncrease the rate of intravenous fluids.
DPrepare the infant for a barium enema.
What the audit caught
The rationale for the keyed option (B) states the nurse must notify the surgeon to 'obtain orders for... rectal saline irrigations.' Current evidence-based guidelines for Hirschsprung-associated enterocolitis (HAEC) emphasize that rectal irrigations are a critical nursing intervention that should be initiated immediately upon suspicion, often under standing protocols, to prevent rapid deterioration. Framing irrigation as requiring a specific provider order before initiation may promote unsafe delay in a life-threatening emergency.
Rejected — do not study this as correctPediatric surgical
A 10-month-old infant is admitted to the pediatric unit with a 24-hour history of colicky abdominal pain, vomiting, and currant jelly stools. The healthcare provider suspects intussusception. Which order should the nurse question?
AAdminister a tap water enema.Keyed by the writer
BInsert a nasogastric tube.
CStart intravenous fluids.
DKeep the infant NPO.
What the audit caught
Rationale for Option A states 'Current practice uses ultrasound-guided hydrostatic or pneumatic reduction'; however, pneumatic (air) reduction is predominantly performed under fluoroscopic guidance in current practice, while ultrasound guidance is standard for hydrostatic (saline) reduction. This generalization is factually imprecise per Instruction #4.
Rejected — do not study this as correctPediatric surgical
A 10-month-old infant is brought to the emergency department with sudden episodes of drawing up the knees and crying, followed by periods of calm. The parent reports the infant passed a stool mixed with blood and mucus that looked like 'red currant jelly.' On assessment, the nurse palpates a sausage-shaped mass in the right upper quadrant. Which action should the nurse take first?
AAdminister the prescribed opioid analgesic for pain relief.
BInsert a nasogastric tube to decompress the stomach.
CObtain informed consent for an air or water-soluble contrast enema.
DEstablish intravenous access to administer fluids and prepare for sedation.Keyed by the writer
What the audit caught
Option C Rationale Factual Accuracy: The rationale implies the nurse could obtain informed consent but prioritizes IV access instead. In most jurisdictions, the provider (MD/NP) obtains informed consent for medical procedures like contrast enemas; the nurse's role is to witness. The rationale should reflect scope of practice, not just priority.
Rejected — do not study this as correctPediatric surgical
A newborn is delivered at 38 weeks' gestation with a visible abdominal wall defect to the right of the umbilical cord. The bowel is protruding without a covering sac. What is the priority nursing action?
AAdminister intravenous antibiotics as prescribed immediately.
BCover bowel with moist sterile dressing and plastic.Keyed by the writer
CPlace infant in Trendelenburg position right away.
DApply dry sterile dressing to exposed bowel.
What the audit caught
Rationale for Option C states definitively that the infant 'should be positioned supine', whereas current evidence-based guidelines often recommend side-lying positioning for gastroschisis to reduce aspiration risk and mesenteric tension, making the absolute statement potentially inaccurate depending on the protocol.
Rejected — do not study this as correctPediatric surgical
A term newborn develops severe respiratory distress shortly after birth. Physical examination reveals a scaphoid abdomen, and bowel sounds are auscultated over the left chest. A chest radiograph confirms a left-sided congenital diaphragmatic hernia. Which nursing intervention is the priority?
AAdminister 100% oxygen via oxygen hood.
BPlace the infant in Trendelenburg position.
CInsert an orogastric tube and connect to low intermittent suction.Keyed by the writer
DPrepare for immediate chest tube insertion.
What the audit caught
Rationale for Option C states 'Low intermittent suction is the standard,' but CDH-specific guidelines (e.g., CDH Study Group, UpToDate) recommend continuous low suction to prevent any gastric accumulation; intermittent suction allows periodic distension which contradicts the goal of maximal decompression.
Rejected — do not study this as correctPediatric surgical
A 3-month-old infant is 4 hours post-operative from cleft lip repair. The nurse notes the infant is awake and crying. Which action should the nurse take first?
AAdminister the prescribed analgesic.
BHold and comfort the infant.Keyed by the writer
CApply elbow restraints to the infant.
DOffer a pacifier to the infant.
What the audit caught
Rationale for Option D is imprecise: Pacifiers are strictly contraindicated for cleft *palate* repair. For cleft *lip* repair, suction is generally avoided, but some protocols allow specific pacifiers; stating it is universally contraindicated for lip repair conflates the two surgical distinctions.