A nurse is caring for a newborn who is formula-fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?
15 mL.
30 mL.
45 mL.
60 mL.
The Correct Answer is D
Choice A rationale:
15 mL is not the correct choice because it only considers the first two feedings and does not account for the intake during the entire shift.
Choice B rationale:
30 mL is not the correct choice because it only considers the first three feedings and does not account for the intake during the entire shift.
Choice C rationale:
45 mL is not the correct choice because it only considers the first four feedings and does not account for the intake during the entire shift.
Choice D rationale:
The nurse should record 60 mL of formula as the newborn's intake for the shift. To calculate the total intake, you add the amounts from each feeding: 0.5 oz + 1 oz + 0.5 oz + 0.5 oz + 0.5 oz = 60 mL. Remember that 1 fluid ounce (oz) is approximately equal to 30 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.
Choice B rationale:
Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.
Choice C rationale:
The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.
Choice D rationale:
Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.
Correct Answer is A
Explanation
"My baby will be placed under special lights if the test is elevated.”.
Choice A rationale:
This statement indicates a need for further teaching. Phenylketonuria (PKU) is a metabolic disorder that leads to the accumulation of phenylalanine in the body. If the PKU test is elevated, it means that the baby has high levels of phenylalanine, and immediate dietary intervention is required. The parent's statement about special lights suggests a confusion with jaundice treatment, which is not related to PKU.
Choice B rationale:
This statement is accurate. Before the PKU test is done, the baby needs to consume formula or breast milk to ensure accurate test results.
Choice C rationale:
This statement is also accurate. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine. By adhering to the prescribed diet, the harmful effects of PKU can be minimized.
Choice D rationale:
This statement is accurate. It is common for the PKU test to be repeated at the 2-week check- up to confirm the initial results and ensure early detection and management of PKU if present.
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