A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take?
Offer to take the newborn to the nursery to finish his feeding.
Insist that the mother pick up the newborn to feed him.
Demonstrate how to hold the newborn and allow the client to practice.
Persuade the client to breastfeed the newborn to promote bonding.
The Correct Answer is A
It is important to ensure the safety of the newborn, and in this situation, the adolescent mother is putting the newborn at risk by leaving him unattended while feeding. Offering to take the newborn to the nursery allows him to finish feeding in a safe environment while also allowing the nurse to assess his feeding and ensure he is receiving adequate nutrition. It is important to provide education to the mother on safe feeding practices, but at this moment, ensuring the safety of the newborn is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nonstress test is a screening tool that assesses fetal well-being. It is performed by monitoring the fetal heart rate (FHR) and uterine contractions (UC) while the client is at rest. The test is considered reactive if there are two or more accelerations of the FHR that reach a certain level above the baseline and last for at least 15 seconds over a 20-min period.
The presence of irregular contractions that are not felt by the client is a finding that is concerning because it could be a sign of uterine hyperstimulation, which can lead to fetal distress. Further diagnostic testing may be needed to assess fetal well-being in this situation.
Option A indicates that the client felt fetal movements during the testing period. This is a reassuring finding because fetal movements are a sign of fetal well-being.
Option B indicates that there were no late decelerations in the FHR with uterine contractions. This is a reassuring finding because late decelerations are a sign of fetal compromise.
Option C indicates that there was an acceleration of the FHR in response to fetal movement. This is a reassuring finding because it indicates that the fetus is capable of responding to stimuli.
Correct Answer is D
Explanation
The nurse should anticipate a urine ketones test for a client who has hyperemesis gravidarum. This test is used to monitor the client's ketone levels, which can increase as a result of excessive vomiting and nausea that can cause dehydration and malnutrition. The other tests mentioned are not typically associated with hyperemesis gravidarum.
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