A mother who is holding her 2-hour-old newborn says, "I don't think she likes breastfeeding, but last time, when we were in the delivery room, she did really well.”. Which is the nurse's best response?
"Your milk isn't in yet. That is why she acts disinterested in eating.".
"Let me help you get her to latch on. Once she takes hold, she'll be fine.".
"After birth, babies go into a deep sleep, but when she wakes up, she'll be hungry.".
"You just need to wake her up so she'll be alert and ready to eat.".
The Correct Answer is B
Choice A rationale:
This response would not be appropriate because it provides incorrect information. Breast milk is already present in the mother's breasts during pregnancy, and the newborn's disinterest in eating is likely due to other factors.
Choice B rationale:
This is the best response because it acknowledges the mother's concern and offers a practical solution to help the newborn latch onto the breast properly. Correct latching is crucial for successful breastfeeding, and once the baby latches on correctly, they are more likely to breastfeed effectively.
Choice C rationale:
While it is true that newborns often experience deep sleep phases, attributing the disinterest in eating solely to deep sleep is not accurate. Offering support and guidance for breastfeeding would be more beneficial.
Choice D rationale:
This response oversimplifies the situation and may not address the actual reason for the newborn's disinterest in feeding. It is essential to help the mother with proper techniques rather than just waking up the baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rooting. Choice A rationale:
The Moro reflex is a startle reflex characterized by the infant's sudden extension and abduction of the arms in response to a loud noise or sudden movement. It is not involved in the initiation of sucking and is unrelated to breastfeeding.
Choice B rationale:
The rooting reflex is a crucial reflex that helps initiate sucking in newborns. When the infant's cheek is stroked or touched, they will turn their head toward the stimulus and open their mouth, preparing for feeding. This reflex helps the infant find the mother's nipple and begin breastfeeding effectively.
Choice C rationale:
The stepping reflex is a primitive reflex observed in newborns when held upright with their feet touching a solid surface. The baby will make stepping movements, mimicking walking. However, this reflex is not related to the initiation of sucking and breastfeeding.
Choice D rationale:
The Babinski reflex is a reflex in which the big toe extends upward and the other toes fan out when the sole of the foot is stimulated. This reflex is present in newborns and disappears as the child grows older. It is not involved in the initiation of sucking.
Correct Answer is C
Explanation
A. A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old: A blood glucose level of 40 mg/dL is borderline low but expected in the immediate postnatal period, especially if the infant is asymptomatic. Feeding the infant is the first step to address this, and monitoring is usually sufficient unless symptoms of hypoglycemia develop.
B. A hematocrit of 60% in an infant who is 8-hr old: This value is at the upper end of normal for a newborn and may suggest mild polycythemia. However, it does not require urgent notification unless accompanied by symptoms such as respiratory distress or poor perfusion
C. Jaundice in an infant who is 4-hr old: Early-onset jaundice (within the first 24 hours) is not normal and suggests a potentially dangerous underlying condition, such as hemolytic disease of the newborn or infection. Immediate reporting and further evaluation, including bilirubin levels and possible treatment with phototherapy, are essential.
D. Acrocyanosis in an infant who is 2-hr old: Acrocyanosis (bluish discoloration of the hands and feet) is a common and benign finding in the first 24 to 48 hours after birth due to immature circulation. It does not require notification or intervention.
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