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National Council Licensure Examination - NCLEX-RN Questions 278–280 (page: 113)

Updated On: 9-Feb-2026

A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:

  1. Gavage tube
  2. Nipple and bottle
  3. A straw and cup
  4. Syringe

Answer(s): D

Explanation:

(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3-month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This
minimizes the amount of sucking needed.



Assessment of a newborn for Apgar scoring includes observation for:

  1. Pupil response
  2. Respiratory rate
  3. Heart rate
  4. Babinski's reflex

Answer(s): C

Explanation:

(A) Pupil response should be assessed but is not part of Apgar scoring. (B) Respiratory effort is an essential part of Apgar scoring, not respiratory rate. (C) Heart rate is the most critical component of Apgar scoring. (D) Assessment of Babinski's reflex is not a component of Apgar scoring.



Assessment of a newborn for Apgar scoring includes observation for:

  1. Pupil response
  2. Respiratory rate
  3. Heart rate
  4. Babinski's reflex

Answer(s): C

Explanation:

(A) Pupil response should be assessed but is not part of Apgar scoring. (B) Respiratory effort is an essential part of Apgar scoring, not respiratory rate. (C) Heart rate is the most critical component of Apgar scoring. (D) Assessment of Babinski's reflex is not a component of Apgar scoring.



A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

  1. Provide respite care for the mother
  2. Facilitate optimal development
  3. Provide a demanding and challenging educational program
  4. Prepare child to enter mainstream education

Answer(s): B

Explanation:

(A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.



A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

  1. Provide respite care for the mother
  2. Facilitate optimal development
  3. Provide a demanding and challenging educational program
  4. Prepare child to enter mainstream education

Answer(s): B

Explanation:

(A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.



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