A nurse is caring for a client who is 1 day postpartum. The client tells the nurse, "The baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse make?
"There's absolutely nothing for you to worry about. Newborns often breathe like this."
"I'll sit here while you feed him and we'll check out his breathing."
"You are going to be a very good, responsible mother to this baby."
"All new mothers feel a bit anxious about things like this."
The Correct Answer is B
Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: An increase in breast milk production is a normal physiological response during breastfeeding and does not indicate mastitis.
Choice B rationale: Mastitis is an inflammation of the breast tissue, usually caused by infection. It commonly occurs in breastfeeding women and is characterized by redness, warmth, swelling, and pain in one breast. The affected breast may also be tender and sore to the touch.
Choice C rationale: Swelling in both breasts is a common occurrence during the early days of breastfeeding as the milk supply adjusts to the baby's needs. It is not specific to mastitis.
Choice D rationale: Cracked and bleeding nipples can be a result of improper latch or positioning during breastfeeding, but they are not specific to mastitis.
Correct Answer is A
Explanation
Choice A rationale: The Moro reflex, also known as the startle reflex, is elicited by making a loud noise or performing a sharp hand clap near the newborn. In response to the stimulus, the newborn will throw their arms and legs outward and then bring them back toward the center of the body.
Choice B rationale: Placing a finger at the base of the newborn's toes is not related to eliciting the Moro reflex. This action may elicit the Babinski reflex, which causes the toes to fan out and the big toe to dorsiflex.
Choice C rationale: This action may elicit the stepping reflex, where the newborn will make stepping movements when the soles of their feet touch a flat surface. It is not related to eliciting the Moro reflex.
Choice D rationale: Turning the newborn's head quickly to one side is not related to eliciting the Moro reflex. This action may elicit the asymmetric tonic neck reflex (ATNR), where the newborn will extend the arm and leg on the side their head is turned to and flex the opposite arm and leg.
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