A nurse is reinforcing teaching about formula feeding with the guardian of a term newborn who was born 2 hr ago.
Which of the following instructions should the nurse include?
You should offer a bottle of formula every 3 to 3 1/2 hours.
You should wake the baby for night feedings for the first few months.
You should add filtered water to dilute ready-to-feed formula.
You can keep prepared bottles in the refrigerator for 72 hours.
The Correct Answer is A
Choice A rationale
The American Academy of Pediatrics recommends that term newborns should be fed on demand or at least every 3 to 4 hours, which provides sufficient caloric intake for growth and prevents hypoglycemia. Formula is digested more slowly than breast milk, so offering a bottle every 3 to 3 1/2 hours is generally appropriate to meet the infant's nutritional needs and satisfy hunger cues. Regular feeding supports adequate weight gain, which is a critical developmental milestone in the neonatal period.
Choice B rationale
For the first few weeks, the nurse should instruct the guardian to wake a sleepy newborn if more than 4 hours have passed since the last feeding to prevent excessive weight loss and hypoglycemia, as their small glycogen stores are rapidly depleted. However, after the initial period and once the infant is feeding well and gaining weight appropriately (usually about 2 weeks old), night waking is typically not necessary.
Choice C rationale
Diluting ready-to-feed formula by adding filtered water is contraindicated because it reduces the caloric and nutrient density below required levels for the newborn's growth. The proper ratio of formula powder or concentrate to water is crucial for providing essential electrolytes, protein, and carbohydrates. Dilution can lead to water intoxication or hyponatremia and cause serious neurological complications due to electrolyte imbalance.
Choice D rationale
Prepared infant formula should be used or discarded within 24 hours if stored in the refrigerator, not 72 hours. Bacteria can rapidly proliferate in prepared formula, even under refrigeration, increasing the risk of gastrointestinal infection for the newborn. Formula ready-to-feed containers, once opened, should also be used within 24 to 48 hours or discarded to maintain optimal safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The lap belt component of the seatbelt should be worn low across the pelvis, under the pregnant abdomen, touching the upper thighs. Wearing it high across the abdomen could apply direct force to the gravid uterus and the fetus during a sudden stop or collision, posing a serious risk of injury and placental abruption.
Choice B rationale
The shoulder harness should be positioned across the middle of the chest, between the breasts, and to the side of the pregnant abdomen. Placing it directly across the gravid uterus or abdomen could concentrate pressure on the fetus during an impact, potentially causing trauma to the fetus or internal organs.
Choice C rationale
Airbags are a crucial safety feature and should generally not be disabled. In a collision, the airbag provides vital cushioning to prevent the driver's chest or head from striking the steering wheel, offering necessary protection to the mother and, indirectly, the fetus. Disabling them increases injury risk.
Choice D rationale
Moving the seat as far away as possible from the steering wheel, while still being able to comfortably reach the pedals and steering wheel, is the safest practice. This maintains a minimum 10-inch distance between the sternum and the steering wheel, ensuring that the airbag has sufficient space to deploy safely without impacting the abdomen.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: A strong cry in a newborn is a reassuring sign of intact respiratory effort, neurologic function, and overall vitality. It reflects adequate lung expansion, vocal cord function, and central nervous system integrity. In neonatal abstinence syndrome (NAS), a strong cry alone does not indicate distress unless it is high-pitched or persistent. Therefore, this finding does not require follow-up and is consistent with normal neonatal behavior.
Choice B rationale: Shallow and irregular respirations may reflect autonomic instability associated with NAS. Opioid withdrawal affects the brainstem centers regulating respiratory rhythm, leading to inconsistent breathing patterns. This can increase the risk of apnea, desaturation, or feeding difficulties. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with periodic breathing, but shallow and irregular patterns in the context of opioid exposure warrant close monitoring and follow-up.
Choice C rationale: A high-pitched cry is a hallmark sign of NAS and indicates central nervous system irritability. It results from increased excitatory neurotransmission and altered pain perception due to opioid withdrawal. This type of cry is often persistent, difficult to console, and reflects heightened neurologic sensitivity. It is distinct from a normal strong cry and requires follow-up to assess severity, initiate scoring protocols, and determine need for pharmacologic or supportive interventions.
Choice D rationale: Increased muscle tone with tremors upon stimulation is a classic manifestation of NAS. Opioid withdrawal disrupts neuromuscular regulation, leading to hypertonia and exaggerated motor responses. Tremors may be spontaneous or stimulus-induced and reflect heightened sympathetic activity. These findings require follow-up to assess withdrawal severity using standardized scoring tools such as the Finnegan scale and to guide management strategies including swaddling, minimizing stimuli, and possible medication.
Choice E rationale: An exaggerated Moro reflex is a sign of central nervous system hyperexcitability, commonly seen in NAS. The Moro reflex is a normal primitive reflex, but when intensified, it reflects neurologic irritability due to withdrawal. This heightened response may interfere with sleep and feeding and contributes to overall distress. Follow-up is needed to monitor progression, evaluate for other neurologic signs, and determine the need for therapeutic interventions.
Choice F rationale: Moist mucous membranes indicate adequate hydration and perfusion. This finding reflects normal fluid balance and is not associated with NAS pathology. It confirms that feeding is sufficient and that there are no signs of dehydration or systemic compromise. Therefore, this finding does not require follow-up and supports stable clinical status in this domain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.