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 A
Explanation
Choice A rationale
A respiratory rate (RR) of 24/min in a 4-hour-old newborn is below the normal range, which is typically 30 to 60 breaths per minute. A sustained low respiratory rate, especially in a neonate, can indicate respiratory depression, central nervous system depression, or impending respiratory failure, necessitating immediate reporting to the healthcare provider for further evaluation and intervention to ensure adequate oxygenation and ventilation.
Choice B rationale
A blood pressure (BP) of 82/44 mm Hg is generally within the expected normal range for a full-term newborn, with typical systolic values ranging from 60 to 90 mm Hg and diastolic values from 30 to 60 mm Hg. This finding reflects adequate cardiac output and vascular tone; therefore, it is considered a reassuring and expected physiological finding that does not require immediate notification of the provider.
Choice C rationale
A temperature of 37.2° C (99° F) falls within the normal range for a newborn, which is typically between 36.5° C and 37.5° C (97.7° F and 99.5° F). This temperature indicates effective thermoregulation and is an expected finding, as newborns maintain a slightly higher core temperature than older children and adults.
Choice D rationale
A heart rate (HR) of 150/min is within the normal resting heart rate range for a newborn, which is typically 110 to 160 beats per minute. Sinus tachycardia can be normal with crying or activity, and 150/min is an expected and acceptable finding that indicates a healthy circulatory status.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
- Cover the newborn's eyes with an eye shield ✅ This is essential to prevent retinal damage from the phototherapy light.
- Reposition the newborn every 2 to 3 hr ✅ Repositioning ensures even exposure to light and prevents pressure injuries.
- Apply lotion to the newborn's skin regularly ❌ Lotion is contraindicated as it may interfere with light absorption and increase the risk of burns.
- Ensure the newborn wears a hat during phototherapy ❌ A hat reduces the surface area exposed to light, decreasing phototherapy effectiveness.
- Move the lights closer to the newborn to increase temperature ❌ Phototherapy lights should be positioned at a safe distance to avoid overheating or burns. Temperature should be monitored, not manipulated this way.
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