DOH Specialty Nurse oral exam prep

Knowledge: Women and people with diabetes often present with epigastric pain, nausea or fatigue rather than classic chest pain, so I treat this as acute coronary syndrome until proven otherwise. The first priority is a 12-lead ECG within 10 minutes of arrival, read for ST elevation, new ST depression, T-wave change and posterior or right-sided involvement. A normal first ECG does not exclude infarction, so I repeat it every 15 to 30 minutes while symptoms continue. High-sensitivity troponin helps, but the ESC 2023 guideline pathways are for a hospital setting and I would not hold her back to wait for a result. Her low-normal pressure makes me think of right ventricular infarction or early shock, which changes how I use nitrates.

Management: I would place her in a monitored bed, give oxygen only if saturation falls below 90 percent, establish IV access and attach defibrillator pads. If there is no aspirin allergy or bleeding history I would give aspirin 300 mg chewed. I would avoid nitrates because her pressure is low and an inferior infarct is possible. I would call the ambulance with a clear handover that says possible ACS in a diabetic woman, and send the ECG ahead so the receiving team can decide on a primary PCI pathway. I would stay with her, repeat observations every 5 minutes, and be ready to start CPR. I would not discharge her or give an antacid and wait.

Ethics and communication: I would explain in plain words what I suspect, why she must go by ambulance and not by private car, and ask her permission to share her records with the receiving hospital. If she declines transfer I would explain the risk clearly, confirm she has capacity, document the discussion and ask a senior clinician to speak to her. Consent for treatment follows Federal Decree-Law No. 4 of 2016 and Cabinet Resolution No. 40 of 2019, with the emergency exception when she cannot decide. I would record times for ECG, aspirin and ambulance call, and review the case afterwards with my medical director.

Reference: ESC Guidelines for the management of acute coronary syndromes (Byrne et al, Eur Heart J 2023); AHA/ACC Chest Pain Guideline (Gulati et al, 2021)

Knowledge: ACE inhibitors and ARBs are fetotoxic, mainly in the second and third trimesters, where they cause renal dysgenesis, oligohydramnios and skull ossification defects. Exposure only in the first trimester carries a small and uncertain risk, so the message is to switch promptly and not to panic. Untreated chronic hypertension also has risks, including superimposed pre-eclampsia, placental abruption and growth restriction, so she should not stop all treatment. Labetalol and extended-release nifedipine are the usual first-line choices, with methyldopa as an older alternative. She should start folic acid and low-dose aspirin 75 to 150 mg daily from 12 weeks to reduce the risk of pre-eclampsia, which NICE advises for chronic hypertension.

Management: I would confirm the pregnancy, ask about her last period, bleeding and pain, and check that it is not ectopic if she has symptoms. I would stop lisinopril today and start labetalol, within my prescribing privileges and the clinic formulary, with a target blood pressure of about 135/85 or lower. I would check renal function and urine protein, arrange early booking with obstetrics and give her a written plan with symptoms that need same-day review, such as headache, visual change and upper abdominal pain. I would teach home blood pressure monitoring and review her in one week. I would also review her other medicines and counsel on rest, salt and avoiding NSAIDs.

Ethics and communication: I would give her honest information in a balanced way and let her take part in the choice. I would document the exposure, the date I stopped the drug and the counselling, and tell her prescriber and obstetrician. If her blood pressure control or the drug choice goes beyond my prescribing scope, I would hand over to the doctor. Her information is confidential and I would share it only with the team caring for her, in line with Federal Law No. 2 of 2019 on health data.

Reference: NICE NG133 Hypertension in pregnancy (2019, updated 2023); ACOG Practice Bulletin 203 Chronic hypertension in pregnancy (2019)

Knowledge: Rising end-tidal CO2 despite higher minute ventilation, tachycardia, rising temperature and masseter rigidity after a volatile and suxamethonium are the classic features of malignant hyperthermia, a hypermetabolic crisis from uncontrolled calcium release in skeletal muscle. Temperature is often a late sign, so I do not wait for it. Differentials include light anaesthesia, sepsis, thyrotoxicosis, phaeochromocytoma and a faulty circuit or exhausted absorber, but the CO2 trend makes MH likely. The specific treatment is dantrolene 2.5 mg/kg IV, repeated up to a total of about 10 mg/kg, together with stopping the triggers. Complications include hyperkalaemia, rhabdomyolysis, acidosis, arrhythmia and disseminated intravascular coagulation.

Management: I would say 'I think this is malignant hyperthermia' aloud and ask for help and the MH trolley. The team stops the volatile and suxamethonium, changes to total intravenous anaesthesia, and ends or hands over the surgery quickly. We hyperventilate with 100 percent oxygen at high flow, and replace the circuit and absorber if the machine allows it. I would mix dantrolene, which needs many vials and large volumes of water, while the anaesthetist gives the first dose, and set up two IV lines. We would start active cooling with cold fluids and ice packs, send blood gases, potassium, CK and lactate, and treat hyperkalaemia and arrhythmia. A urinary catheter would be placed to watch myoglobinuria, and he would go to intensive care for at least 24 hours with CK monitored.

Ethics and communication: After the crisis the family needs a clear and honest explanation of what happened and the risk of MH in close relatives. He should be referred for susceptibility testing and given a written alert. I would take part in the incident report and debrief. As a nurse I act on the anaesthetist's direction and the facility protocol, but I speak up at once when I see a danger. Consent covered the risks of anaesthesia and disclosing this event follows Federal Decree-Law No. 4 of 2016 on medical liability and the principle of honest disclosure.

Reference: Hopkins PM et al, Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists (Anaesthesia 2021)

Knowledge: This is local anaesthetic systemic toxicity, typically from inadvertent intravascular injection or rapid absorption. The dose here is 150 mg of bupivacaine for a 70 kg patient, around 2.1 mg/kg, which is within the usual maximum of 2 to 3 mg/kg, so the danger comes from the site and speed and not the total dose alone. Early signs are perioral numbness, metallic taste and tinnitus, then seizure, then cardiovascular collapse with arrhythmia. Bupivacaine is especially cardiotoxic because it binds sodium channels strongly. The antidote is 20 percent lipid emulsion: a bolus of 1.5 mL/kg over 2 to 3 minutes, about 100 mL for this patient, then an infusion of 0.25 mL/kg/min, with repeat boluses if she remains unstable, up to a maximum of about 12 mL/kg.

Management: I would call for help and the LAST kit, stop any further injection and secure the airway with 100 percent oxygen to prevent hypoxia and acidosis. A benzodiazepine such as midazolam is the first line for the seizure, and I would avoid propofol in large doses because it depresses the circulation. I would draw up and give the lipid bolus as directed, start the infusion pump and note the time. If she arrests, CPR continues for a long period, adrenaline is given in small doses of 1 microgram/kg or less, and I would avoid vasopressin, calcium channel blockers and beta blockers. She needs prolonged monitoring after lipid: ASRA advises at least 4 to 6 hours after a cardiovascular event, and many protocols keep patients 12 hours or more. The pancreatitis risk should be considered.

Ethics and communication: I would complete the record carefully with doses and times, report the event through the facility's incident system and report the use of lipid emulsion to the relevant safety registry according to local policy. The patient should be told what happened, why, what was done and what the follow-up is. I work as a nurse under the anaesthetist's direction, and I would speak up if I saw an unsafe dose or technique. Informed consent for the block should have included the possibility of toxicity, as required by Cabinet Resolution No. 40 of 2019.

Reference: Neal JM et al, ASRA Practice Advisory on Local Anesthetic Systemic Toxicity (Reg Anesth Pain Med 2018); ASRA LAST checklist (2020); Association of Anaesthetists Guideline for the management of severe LAST (2010)

Knowledge: A full-thickness wound with visible fat and slough but no bone, tendon or muscle is a stage 3 pressure injury. Slough means I cannot be sure of the true depth, and if I could not see the base I would call it unstageable. The main causes are prolonged pressure and shear from sitting reclined, poor nutrition, possible incontinence and reduced mobility. I would check for infection, local signs such as spreading erythema, warmth, increasing pain and odour, and systemic signs, and I would consider diabetes, anaemia and peripheral vascular disease. Wound healing needs about 30 to 35 kcal/kg a day and 1.25 to 1.5 g/kg of protein according to the international guideline, so his weight loss matters.

Management: I would assess the wound with measurement and photographs after consent, cleanse it, and debride slough according to my competence, using sharp debridement only if trained and authorised. A moist dressing such as foam or hydrofiber is chosen by exudate level. Offloading comes first: a pressure-redistributing mattress and cushion, repositioning every 2 to 4 hours according to his tissue tolerance, and a 30 degree side-lying position and not a high recline. I would refer him for dietitian review and medical review for the weight loss, and ask the doctor if swab or antibiotics are needed. I would teach the domestic worker the repositioning routine in clear steps with a written chart, and review the wound weekly.

Ethics and communication: I would ask for his consent for photos and care, and explain the plan in his own language. I would avoid blaming the domestic worker, and see her as part of the team who needs training and support. If I found neglect that put him at serious risk, I would escalate to the supervising physician and follow my organisation's policy on vulnerable adults. I would also speak with the son with the patient's permission, because health data is confidential under Federal Law No. 2 of 2019.

Reference: NPIAP/EPUAP/PPPIA International Guideline: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (2019, 3rd ed)

Knowledge: Fever, cough, conjunctivitis and a descending maculopapular rash with Koplik spots point to measles. He is infectious from about 4 days before to 4 days after the rash starts, so everyone in the waiting room, especially the unvaccinated infant, has been exposed. Complications include otitis media, pneumonia (the usual cause of death), encephalitis, and in the longer term subacute sclerosing panencephalitis. Malnutrition and vitamin A deficiency raise the risk. Treatment is supportive, plus vitamin A for children with measles as WHO advises, for example 200,000 IU for a child of 12 months or older, given for two days.

Management: I would put a mask on him and move him with his mother immediately to a separate room with a closed door, ideally an airborne isolation room, and wear an N95 respirator myself after checking my own immunity. I would assess hydration, breathing and signs of complications and refer him to hospital if he is unwell, in a pre-arranged way that warns the receiving unit. I would list everyone who shared the waiting area and clinic space. Susceptible contacts can receive MMR within 72 hours of exposure, and high-risk contacts such as the infant may need immunoglobulin within 6 days, which I would arrange with the physician. I would notify the case to the health authority at once, without waiting for a laboratory result.

Ethics and communication: Measles is a notifiable disease under Federal Law No. 14 of 2014 on the Prevention of Communicable Diseases, and I would report it as required. I would keep the family's information confidential and share it only with those who need it for public health action. I would explain to the mother, without blame, why vaccination matters and offer to catch up his siblings. I would document the exposure list and the advice given to every parent in the waiting area.

Reference: WHO Measles fact sheet and Guidelines for Measles Surveillance (2018); Federal Law No. 14 of 2014 (UAE)

Knowledge: This is septic shock from a presumed abdominal source, possibly an anastomotic leak, with hypotension needing vasopressors and a lactate above 2 mmol/L. The Surviving Sepsis Campaign 2021 guideline says antimicrobials should be given within one hour for shock, with cultures taken first if this causes no delay. It suggests 30 mL/kg of crystalloid in the first 3 hours for sepsis-induced hypoperfusion, guided by reassessment, and noradrenaline as the first-line vasopressor, starting peripherally if needed to avoid delay. The target mean arterial pressure is 65 mmHg. Vasopressin is added when noradrenaline reaches about 0.25 to 0.5 micrograms/kg/min, and hydrocortisone 200 mg a day if vasopressor need persists. Capillary refill and lactate trends guide resuscitation.

Management: I would call the ICU physician and surgeon immediately and state 'septic shock, MAP below 65 after 30 mL/kg'. I would obtain two sets of blood cultures and a lactate repeat, then give the prescribed broad-spectrum antibiotic as soon as it is ordered, and chase it if it is late. I would start the noradrenaline infusion through a large peripheral cannula, and prepare for central and arterial lines. I would check the infusion concentration and rate with a second nurse, observe the cannula for extravasation, and monitor MAP continuously, urine output hourly and temperature. I would prepare for source control, such as imaging or theatre, and make sure oxygen and airway support are ready. Fluids are given in 250 to 500 mL aliquots with reassessment.

Ethics and communication: I would update his family honestly, explain that he is very ill and that the team is acting urgently, and record who I spoke with. All medicines are checked to the five rights. If a doctor delayed antibiotics, I would use the chain of command, as patient safety comes first. Care is documented with times, and an incident report is filed if a delay occurred. Treatment without delay is justified by the emergency exception to consent in Cabinet Resolution No. 40 of 2019 when he lacks capacity.

Reference: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 (Evans et al, Crit Care Med 2021)

Knowledge: Acute desaturation with high airway pressure after turning has a short list of causes, which I remember as DOPES: displacement of the tube, obstruction, pneumothorax, equipment failure and stacked breaths or secretions. The tube has moved from 22 to 18 cm, so a mucosal or endobronchial change is possible, but a tube pulled back can also have its cuff near the cords. Obstruction by a mucus plug or biting also raises peak pressure. A pneumothorax is likely in a patient with lung disease and high pressures and needs a chest drain urgently. If peak pressure is high but plateau pressure is normal, the problem is resistance in the airway or tube, and if both are high, it is the lung, the chest wall or a pneumothorax.

Management: I would call for help, disconnect her from the ventilator and ventilate by hand with 100 percent oxygen to feel the compliance. I would check the capnography trace, as a flat trace means the tube is out of the trachea. I would pass a suction catheter to test the tube, listen for breath sounds on both sides, and look for chest wall movement, tracheal shift or surgical emphysema. If the tube is out of place, the doctor will reposition or reintubate, and I would prepare the airway trolley, laryngoscope and drugs. If I suspect a tension pneumothorax, I would prepare for needle decompression and chest drain. After stabilising her, I would arrange a chest X-ray and blood gas, secure the tube again and check the cuff pressure.

Ethics and communication: I would tell the doctor and the family what happened and how it was managed. I would write an incident report because a tube displacement during turning is a patient safety event and may lead to improvement in the turning technique, such as a second nurse to support the tube. I would reflect with the team without blame. Disclosure to the patient's relatives follows the honest-communication principles that underpin Federal Decree-Law No. 4 of 2016 on medical liability.

Reference: Marino's The ICU Book (4th ed, 2014); Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults (Higgs et al, Br J Anaesth 2018)

Knowledge: A tracheostomy that will not pass a suction catheter in a hypoxic child is blocked or displaced until proven otherwise, and this is a life-threatening airway emergency. The upper airway may be inadequate in a child with a neurological condition, so oxygen by mouth or face mask alone may not work. The causes are mucus plugging, a tube pressed against the carina or wall, a kinked or dislodged tube, and a decannulation. Because tubes are short in children, they can come out easily. The order is: call for help, clear or change the tube, and bag the child through the stoma or the mouth with oxygen.

Management: I would ask the mother to call the emergency number and state that this is a child with a blocked tracheostomy, and to bring the emergency bag. I would remove the inner tube and clean or replace it, and try suction again. If the airway is still blocked, I would deflate the cuff if present, remove the whole tube and replace it with a spare tube of the same size, with a smaller size ready, using the obturator and the lubricant. If I cannot replace it, I would give oxygen to the stoma with a paediatric mask and ventilate by bag, covering the stoma if I use the mouth. I would continue until the ambulance arrives, hand over the child's details and equipment, and record times and findings.

Ethics and communication: After the child is safe I would speak with the family kindly, and explain what went wrong and what we will change. Emergency equipment, a second tube, suction and a trained second carer should be in the home, and the mother should have been trained in emergency tube change, in line with my agency's policy. I would write an incident report and speak with the physician for the care plan. Consent for emergency actions follows the guardian's consent in Cabinet Resolution No. 40 of 2019, and the emergency exception applies when there is no time.

Reference: Mitchell RB et al. Clinical Consensus Statement: Tracheostomy Care (Otolaryngol Head Neck Surg 2013); National Tracheostomy Safety Project emergency algorithms (2013)

Knowledge: Pain control follows the WHO approach: regular analgesia, with breakthrough doses as needed, and titration to effect. With 40 mg of oral morphine daily, a breakthrough dose is about one sixth of the daily dose, so around 5 to 7.5 mg of immediate-release oral morphine, which can be repeated hourly if needed, and the regular dose is then adjusted by the total used in 24 hours. Opioids always need a laxative, since constipation will not settle by itself, and an antiemetic such as haloperidol or metoclopramide if nausea is opioid-related. Drowsiness may signal opioid toxicity, renal impairment or hypercalcaemia, so I would look for myoclonus, small pupils and a low respiratory rate. Neuropathic and coeliac plexus pain may need adjuvants or a nerve block, which needs a specialist.

Management: I would assess the pain fully, including its site, character and effect on sleep, and check hydration, bowel history and the drug chart. I would phone the palliative physician the same day with the findings and ask for changes to the dose, breakthrough orders and a laxative, since I do not adjust opioids beyond my authority. I would check the home supply and safe storage of the opioid, teach the family the schedule and warning signs and leave a written plan with the on-call number. I would arrange a review within 24 hours and consider a subcutaneous route if he cannot swallow. I would also ask about his mood, spiritual needs and what matters most to him.

Ethics and communication: The patient has a right to know about his condition if he wishes it. I would speak with him alone, ask how much he wants to know and who he wants to share the information with, then tell him the truth gently. I would explain to the son that hiding the facts can harm trust and prevent the patient from making his own plans, while respecting his love and culture, and offer to hold a family meeting. If the patient prefers not to know, that is his decision, and I record it. Consent and information-sharing follow Cabinet Resolution No. 40 of 2019 and the confidentiality duties in Federal Law No. 2 of 2019.

Reference: WHO Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018); Palliative Care Formulary (7th ed, 2020)

Knowledge: This is bronchiolitis, a viral lower respiratory infection in infants, most often from RSV, with peak severity on days 3 to 5. Management is supportive. The NICE guideline NG9 recommends referral and admission when there is apnoea, a respiratory rate above 60, an oxygen saturation below 92 percent in air, or oral intake under 50 percent of usual. He meets all of these. A rising respiratory rate with tiring, grunting, nasal flaring or an altered level of consciousness suggests impending respiratory failure, and a pediatric early warning score helps decisions. Chest X-ray, antibiotics, bronchodilators and steroids are not recommended routinely.

Management: I would place him in a monitored area with continuous saturation monitoring, and give humidified oxygen by nasal cannula or mask to keep his saturation at or above 92 percent. I would clear the nose with gentle suction and keep him in a comfortable position, minimal handling and calm parents. Feeding will be by nasogastric tube or IV fluids at maintenance if he cannot feed safely, with care not to overload him. I would inform the doctor at once and prepare for high-flow nasal cannula if oxygen need or work of breathing increases. I would repeat observations every 15 minutes at first, record fluids in and out, and prepare for escalation to PICU.

Ethics and communication: I would explain to his parents what bronchiolitis is, why he needs oxygen and what signs would mean worsening, and answer their questions about antibiotics. Parents must be involved and consent for procedures, as under-18 consent is given by the guardian. Infection control matters because RSV spreads easily: hand hygiene, cohorting and cleaning. I would document everything carefully. If the infant had apnoea or was very small or premature, I would raise the level of care without delay.

Reference: NICE NG9 Bronchiolitis in children: diagnosis and management (2015, updated 2021); AAP Clinical Practice Guideline: Bronchiolitis (Ralston et al, Pediatrics 2014)

Knowledge: Fractures in a non-ambulatory infant are suspicious for non-accidental injury, especially when the mechanism does not match the injury, the history changes, there is delay in seeking care and other signs are present. A spiral femur fracture in an 8-month-old, a bruise in an unusual site such as the back and a torn frenulum are red flags. Skeletal survey, assessment for abusive head trauma, and bleeding or bone-disease tests would be considered by the doctor, as differentials include osteogenesis imperfecta, rickets and a bleeding disorder. I would not accuse anyone. My duty is to describe, document and report.

Management: I would give pain relief as ordered, immobilise and elevate the limb and make the infant safe and comfortable. I would not leave her alone with unsupervised visitors until the team decides. I would write down the history in the father's own words with the time and exact quotes, record bruises on a body map with measurements and take photographs only according to hospital policy. I would inform the doctor and the child protection team lead at once, and follow the hospital child protection procedure, including a full skeletal survey and eye examination ordered by the doctor. I would be calm and respectful with the father, and not question him as an investigator.

Ethics and communication: Federal Law No. 3 of 2016 on Child Rights (Wadeema's Law) requires health professionals to report suspected abuse, so I would report it through the hospital process and I would not wait for proof. Confidentiality does not prevent reporting, and I would not discuss the suspicion with the father in a confrontational way. The mother and father are guardians, but the child's best interests come first. I would record only facts, avoid opinions about guilt and support the family who may be under stress.

Reference: WHO Preventing child maltreatment: a guide to taking action and generating evidence (2006); RCPCH Child Protection Evidence: Fractures (2020); Federal Law No. 3 of 2016 (UAE)

Knowledge: He has a psychotic illness, with persecutory delusions that drive his refusal and agitation, and the risk is escalating. I assess for medical causes, intoxication and pain, and I review his history of violence and what helped before. De-escalation techniques come first: a calm voice, space, short and clear sentences, validating his fear without agreeing with the delusion, offering choices and food that he can open himself. Rapid tranquillisation is a last resort after verbal measures and oral medicine have failed, and physical restraint is the last resort of all, used for the shortest time possible. A medical check is needed afterwards because sedation and restraint carry risks, including cardiorespiratory harm.

Management: I would assess risk and make sure staff are in a good number, with a team leader who speaks to him, and move the frightened patient to a quiet area. I would offer oral medicine for agitation in a non-threatening way, as prescribed, and explain what it does. If he becomes violent and the plan is parenteral medicine or restraint, I would follow the ward policy: a lead for the head, trained staff, continuous observation of airway and breathing, and monitoring of vital signs after medicine. I would record the incident, debrief the patient and staff, and review the care plan with the psychiatrist, including a review of the medicine and a long-acting injection if he continues to refuse.

Ethics and communication: Under Federal Law No. 10 of 2019 on Mental Health, involuntary treatment requires a mental disorder with serious risk and follows the review safeguards in the law, and I would make sure his status and rights are correctly recorded and explained to him. Coercion must be proportionate and documented. I would respect his dignity and religion, such as food preferences, offer an interpreter if needed, and inform his family with his consent. I would explain to the other patients how we keep the ward safe without giving confidential details.

Reference: NICE NG10 Violence and aggression: short-term management in mental health, health and community settings (2015); Federal Law No. 10 of 2019 (UAE)

Knowledge: A deliberate overdose is a major risk marker for later suicide, and a statement that the act was a mistake does not reduce my concern. I assess intent at the time, planning, the lethality of the method, whether she expected to be found, current ideas of suicide, hopelessness, and her protective factors such as relationships and future plans. Risk factors include recent job loss, living alone, alcohol use and previous attempts. Structured tools such as the Columbia Suicide Severity Rating Scale help, but they support judgment and do not predict. Alcohol worsens impulsivity, and I would also screen for depression and other disorders.

Management: I would speak with her in private, calmly and without judgment, and ask directly about suicidal thoughts. I would involve the psychiatrist or liaison team before discharge, since she should not leave without a psychiatric assessment. With her, I would make a safety plan: warning signs, coping steps, people to contact, crisis numbers and removal of means, such as limiting stored medicines. I would arrange follow-up within a short time of discharge, share information with the community team and her GP with her agreement, and offer support for alcohol. If she is judged at high risk, she may need admission.

Ethics and communication: Health data is confidential under Federal Law No. 2 of 2019, and I would ask her permission to involve her parents, and explain why it may help. If there is a serious and immediate risk to her life and she refuses, I would follow the facility policy on sharing information to protect life, discuss it with the psychiatrist and document the reasons. If she needs involuntary admission, Federal Law No. 10 of 2019 applies and requires a mental disorder and serious risk. I would treat her with respect and avoid blame.

Reference: WHO mhGAP Intervention Guide Version 2.0 (2016); Stanley B, Brown GK, Safety Planning Intervention (Cogn Behav Pract 2012); Federal Law No. 10 of 2019 (UAE)

Knowledge: Jaundice in the first 24 hours of life is never normal and should be treated as haemolytic disease until proven otherwise. A mother who is O negative suggests Rhesus or ABO incompatibility, in which maternal antibodies cross the placenta and destroy the baby's red cells. The risk is rapid bilirubin rise and kernicterus, so I compare the bilirubin with the gestation-specific treatment threshold chart, as in NICE NG98 or the AAP 2022 nomogram, and consider the rate of rise. The workup includes baby's blood group, direct antiglobulin test, full blood count, reticulocytes and G6PD if relevant. Breastfeeding jaundice or sepsis may contribute, but should not be assumed.

Management: I would tell the neonatologist at once, since the level is high for 20 hours. I would start intensive phototherapy as ordered, with the baby naked except for a nappy and eye protection, with a light at the right distance and irradiance checked. I would continue breastfeeding, offering feeds every 2 to 3 hours and supplement if directed, and monitor temperature, hydration, weight and urine and stool output. Serum bilirubin would be repeated every 4 to 6 hours or as ordered, and the glucose checked. If the level approaches the exchange transfusion threshold or signs of acute bilirubin encephalopathy appear, such as lethargy, high-pitched cry or arching, I would prepare for exchange transfusion and escalate to NICU.

Ethics and communication: I would explain to the parents why this is serious but treatable, why the baby is under the lamp, that she can come out for feeds and cuddles, and that follow-up after discharge is needed. I would document the maternal antibody status, results and times. Consent for phototherapy and exchange transfusion is given by the parents as guardians, under Cabinet Resolution No. 40 of 2019. I would support breastfeeding and the mother's wishes, respect privacy, and make sure the parents understand warning signs.

Reference: NICE NG98 Jaundice in newborn babies under 28 days (2016, updated 2023); Kemper AR et al, Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn 35 or More Weeks (Pediatrics 2022)

Knowledge: Abdominal distension, bilious aspirates, blood in the stool and systemic signs such as apnoea and lethargy in a preterm baby on feeds suggest necrotising enterocolitis, an inflammatory bowel necrosis with a high mortality. Prematurity is the main risk factor, with feed advancement, hypoxia and infection also contributing. Bell staging classifies disease from suspected through to advanced with perforation. Abdominal X-ray may show dilated loops, pneumatosis intestinalis, portal venous gas or free air. Differentials include sepsis, feeding intolerance and spontaneous intestinal perforation, but I treat it as NEC until the team decides otherwise.

Management: I would stop all enteral feeds, make the baby nil by mouth and place an open nasogastric tube on low intermittent suction. I would call the neonatologist and prepare for blood tests, cultures, a gas and an abdominal X-ray, and start IV access for fluids, parenteral nutrition and broad-spectrum antibiotics as ordered. I would support breathing with oxygen or ventilation and keep him warm, monitor vital signs continuously and measure abdominal girth. I would watch for shock and perforation, and arrange a paediatric surgical review early. I would keep careful intake and output records, including the stool character.

Ethics and communication: I would explain to the parents honestly that he is seriously ill, what NEC is and what we are doing, in simple language and with an interpreter if needed. I would allow them to be present if possible, support them emotionally, and document the discussion. Consent for surgery is given by the parents as guardians, as described in Cabinet Resolution No. 40 of 2019, with the emergency exception if no one can be reached in time. If the mother is expressing milk, I would reassure her it will be useful later, and respect their cultural and religious needs, including their wishes on prayer and naming.

Reference: Neu J, Walker WA, Necrotizing enterocolitis, N Engl J Med 2011; Gleason CA, Juul SE, Avery's Diseases of the Newborn (10th ed, 2018)

Knowledge: Bleeding over 500 mL after vaginal birth is postpartum haemorrhage and a loss approaching 1000 mL is severe, so this is an emergency. The causes are remembered as the four Ts: tone (uterine atony, the commonest, as a boggy uterus suggests), trauma, tissue (retained placenta) and thrombin (coagulopathy). Risk factors in this case include high parity. A pulse of 112 shows she is already compensating, and young women hide shock until late. WHO recommendations support uterine massage, an IV uterotonic such as oxytocin, tranexamic acid 1 g IV within 3 hours of birth, and escalation to bimanual compression and surgical measures if bleeding continues.

Management: I would call for help at once and say 'postpartum haemorrhage' loudly, activating the emergency bell and the call for the midwife and obstetrician. I would rub up the fundus with firm uterine massage, ask her to empty her bladder or catheterise if trained and authorised, and keep her flat and warm. Within my scope and unit protocol, I would insert two large IV cannulas and take bloods including a cross-match, and help the midwife to give oxytocin and tranexamic acid. I would estimate blood loss by weighing, monitor pulse, pressure and consciousness every few minutes, and give oxygen. I would record the times and keep the baby with the mother if safe.

Ethics and communication: I act within my role and the unit's protocol, I do not give drugs or perform procedures that I am not authorised to do, but I must not delay calling for help. I would explain to the woman and her husband what is happening in plain words, and keep them calm. Accurate documentation of blood loss, times and actions is essential. After the event I would join a debrief and incident review. Informed consent for treatment, including blood transfusion, follows Cabinet Resolution No. 40 of 2019, with the emergency exception if she cannot decide.

Reference: WHO Recommendations for the prevention and treatment of postpartum haemorrhage (2012) and WHO recommendation on tranexamic acid for the treatment of PPH (2017); WOMAN Trial Collaborators, Lancet 2017

Knowledge: A blood pressure of 140/90 or more after 20 weeks with new proteinuria means pre-eclampsia until proven otherwise. A headache that persists, together with reduced fetal movements, suggests worsening disease and placental insufficiency. Severe features include pressure of 160/110 or higher, severe headache, visual symptoms, upper abdominal pain, abnormal liver enzymes, a low platelet count and renal impairment. She is in the non-severe range, but with symptoms she needs same-day assessment, since eclampsia, HELLP and abruption can develop quickly. Reduced fetal movements need a CTG and ultrasound to check fetal wellbeing.

Management: I would stay calm, repeat the blood pressure with the right cuff size, and inform the registered midwife and obstetrician at once. I would not send her home. I would arrange immediate transfer to the labour or assessment unit, with a handover that includes the readings, symptoms and fetal movements, and I would accompany her or ensure she is accompanied by a staff member. I would ask about visual changes, epigastric pain and clonus only within my training. The team will arrange CTG, blood tests, urine ratio, antihypertensives and magnesium sulfate if severe features exist, plus steroids for fetal lung maturity if early delivery is likely.

Ethics and communication: I would speak with her and her husband respectfully, with a female staff member if she prefers, and explain that these are warning signs of a condition which can harm both mother and baby, and the safest place is the hospital. I would ask for her own wishes, because she is the one to consent, as Cabinet Resolution No. 40 of 2019 requires informed consent from the patient. If she declines, I would document her decision, explain the risks, give written advice and inform the obstetrician. I would not diagnose or prescribe outside my role.

Reference: NICE NG133 Hypertension in pregnancy (2019, updated 2023); ACOG Practice Bulletin 222 Gestational Hypertension and Preeclampsia (2020)