[{"data":1,"prerenderedAt":63},["ShallowReactive",2],{"q-nurse-113-2-maternal-pediatric-045":3},{"subject":4,"subjectSlug":5,"subjectFullName":4,"question":6,"related":33,"lastmod":62},"產兒科護理學","maternal-pediatric",{"id":7,"webId":8,"year":9,"session":10,"subject":4,"number":11,"stem":12,"options":13,"answer":18,"answerNote":19,"images":20,"explanation":21,"explanationDeep":22,"topics":23,"freq":26},"nurse-113-2-產兒科護理學-045","nurse-113-2-maternal-pediatric-045",113,2,45,"有關病童放置鼻胃管之護理照護，下列敘述何者較適當？",{"A":14,"B":15,"C":16,"D":17},"鼻胃管插入長度為由鼻尖至耳垂之直線距離","測試放置正確與否，可將鼻胃管末端浸入水中需出現氣泡","鼻胃管灌食的總量，不需考慮殘餘量","管灌結束後宜採右側半坐臥或坐姿，頭部抬高 30 度","D",null,[],"本題考點在於病童鼻胃管留置的照護技術。管灌結束後應維持頭部抬高、採半坐臥或坐姿約 30 分鐘至 1 小時，利用重力促進胃排空、減少胃食道逆流與吸入性肺炎的風險，故 D 較適當。A 錯，鼻胃管插入長度的測量為「鼻尖→耳垂→劍突」（NEX 測量法），而非僅「鼻尖至耳垂」，僅量到耳垂長度不足會使管端未達胃部。B 錯，將鼻胃管末端浸入水中看氣泡是「誤入呼吸道」的表現（不應出現氣泡代表在胃內），此法既不可靠亦非正確確認方式；確認位置應以抽取胃內容物測 pH 或影像為準。C 錯，管灌前應先反抽並評估胃殘餘量（residual volume），殘餘過多需延後或減量以防脹氣與逆流吸入，不可「不需考慮殘餘量」。本題須掌握鼻胃管長度測量、位置確認與灌食前後的安全照護原則。","鼻胃管照護要點：長度測量用 NEX 法（鼻尖 Nose→耳垂 Earlobe→劍突 Xiphoid），小兒亦可用鼻—耳—劍突與臍中點法以更貼近胃部。位置確認的可靠方法為抽取胃內容物測 pH（胃液呈酸性 pH≤5.5）或影像學確認，聽診打氣（auscultation）與浸水看氣泡皆不可靠且氣泡反提示誤入氣道。灌食前反抽評估胃殘餘量，殘餘過多反映胃排空不良，須暫停或減量以防腹脹、逆流與吸入。灌食時採半坐臥、灌畢維持坐姿或頭高 30–45 分鐘。記憶法：鼻胃管「NEX 量長度、抽胃液測酸鹼、灌前看殘餘、灌後坐一陣」。",[24,27,29,31],{"term":25,"count":26},"鼻胃管NEX測量法",1,{"term":28,"count":26},"鼻胃管位置確認pH",{"term":30,"count":26},"胃殘餘量評估",{"term":32,"count":26},"管灌後半坐臥防吸入",[34,38,43,48,53,58],{"webId":35,"stem":36,"number":37,"year":9,"session":10},"nurse-113-2-maternal-pediatric-046","王小美，5 歲，罹患巨結腸症（megacolon），進行腸道無神經節部位切除，有關術後之護理措施與指導，下列敘述何者錯誤？",46,{"webId":39,"stem":40,"number":41,"year":42,"session":26},"nurse-114-1-maternal-pediatric-042","有關苯酮尿症（phenylketonuria）之護理指導，下列何者錯誤？",42,114,{"webId":44,"stem":45,"number":46,"year":42,"session":47},"nurse-114-3-maternal-pediatric-036","有關嬰兒玫瑰疹（roseola infantum）在發疹期的敘述，下列何者正確？",36,3,{"webId":49,"stem":50,"number":51,"year":52,"session":10},"nurse-106-2-maternal-pediatric-004","有關精液分析檢查的說明，下列何者錯誤？①禁慾 3～7 天再採檢 ②使用保險套和性交中斷法來收集精液 ③留取精液後 2～3 小時內送至檢查地點 ④精液必須冷凍保存",4,106,{"webId":54,"stem":55,"number":56,"year":57,"session":10},"nurse-107-2-maternal-pediatric-048","協助罹患腦瘤病童之家庭正向因應疾病時，下列護理照護何者較不適當？",48,107,{"webId":59,"stem":60,"number":10,"year":61,"session":26},"nurse-109-1-maternal-pediatric-002","具有伸展會陰部肌肉功用的產前運動項目，下列何者最相關？",109,"2026-09-04",1788510755716]