A nurse is reinforcing discharging teaching with a client who is 2 days postpartum. Which of the following statements should the nurse include in the teaching?
"If you give formula to your newborn, expect at least one stool every 3 days.".
"If you breastfeed your newborn, expect two to three stools per day.".
"You should feed your newborn formula every 2 hours.".
"You should breastfeed your newborn five to seven times each day.".
The Correct Answer is B
Choice A reason:
This is incorrect because formula-fed newborns typically have one or more stools per day, not every 3 days. Stooling less frequently than once a day may indicate constipation.
Choice B reason:
This is correct because breastfed newborns usually have two to three stools per day, which are soft and yellow. Breastfed babies may also have stools less frequently, even once every 10-14 days, as long as the stool is soft.
Choice C reason:
This is incorrect because newborns should be fed formula on demand, not on a strict schedule. The average feeding interval for formula-fed newborns is about 3 to 4 hours.
Choice D reason:
This is incorrect because newborns should be breastfed eight to 12 times per day, not five to seven times. Breastfeeding more frequently helps to establish milk supply and prevent engorgement. - Stanford Medicine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","H"]
Explanation
Choice A:
Blood pressure. The normal blood pressure range for a newborn is 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic. The baby's blood pressure is low, which could indicate shock, dehydration, infection, or heart failure. This requires immediate follow-up to identify and treat the cause.
Choice B:
Gastrointestinal disturbances. Gastrointestinal disturbances such as vomiting and diarrhea are common symptoms of neonatal abstinence syndrome (NAS), which is a withdrawal syndrome of infants after birth caused by in-utero exposure to drugs of dependence, most commonly opioids. These symptoms are not life-threatening and can be managed with supportive care such as hydration, nutrition, and comfort measures.
Choice C:
Skin color. Skin color is not a reliable indicator of NAS, as it can vary depending on the baby's ethnicity, temperature, oxygenation, and circulation. Skin color alone does not require immediate follow-up unless it is accompanied by other signs of distress such as cyanosis, pallor, or jaundice.
Choice D:
NAS score. NAS score is a tool used to assess the severity of withdrawal symptoms in infants with NAS. It includes items such as tremors, irritability, sleep problems, muscle tone, reflexes, seizures, yawning, sneezing, feeding, vomiting, stooling and temperature. A high NAS score indicates that the baby needs more intensive treatment such as medication to ease the withdrawal process. A low NAS score indicates that the baby is coping well and may not need medication. The NAS score should be monitored frequently and adjusted according to the baby's response.
Choice E:
Temperature. The normal temperature range for a newborn is 36.5 to 37.5°C (97.7 to 99.5°F). The baby's temperature is high, which could indicate infection, dehydration or hyperthermia. This requires immediate follow-up to identify and treat the cause.
Choice F:
Oxygen saturation. The normal oxygen saturation range for a newborn is 95 to 100%. The baby's oxygen saturation is within the normal range and does not require immediate follow- up unless it drops below 90% or rises above 100%, which could indicate hypoxia or hyperoxia respectively.
Choice G:
Central nervous system disturbances. Central nervous system disturbances such as seizures, tremors, irritability, and overactive reflexes are common symptoms of NAS. These symptoms are not life-threatening and can be managed with supportive care such as swaddling, rocking, dimming lights, and reducing noise.
Choice H:
Respiratory rate. The normal respiratory rate range for a newborn is 40 to 60 breaths per minute. The baby's respiratory rate is high, which could indicate respiratory distress, infection, pain, or anxiety. This requires immediate follow-up to identify and treat the cause.
Correct Answer is C
Explanation
Choice A reason:
Holding the newborn vertically, allowing one foot to touch the crib surface, will elicit the stepping reflex, not the Moro reflex. The stepping reflex is when the newborn makes stepping movements when held upright with one foot touching a flat surface.
Choice B reason:
Turning the newborn's head quickly to one side will elicit the tonic neck reflex, not the Moro reflex. The tonic neck reflex is when the newborn assumes a "fencing”. position, with the arm and leg extended on the side to which the head is turned and the opposite arm and leg flexed.
Choice C reason:
Performing a sharp hand clap near the infant will elicit the Moro reflex, also known as the startle reflex. The Moro reflex is when the newborn responds to a sudden loss of support or a loud noise by extending and abducting the arms, spreading the fingers, and then bringing the arms together and crying.
Choice D reason:
Placing a finger at the base of the newborn's toes will elicit the Babinski reflex, not the Moro reflex. The Babinski reflex is when the newborn fans out the toes and dorsiflexes the big toe when the sole of the foot is stroked.
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