A nurse is reinforcing teaching with a caregiver about how to safely prepare formula for their 3-day-old newborn. Which of the following statements should the nurse include in the teaching?

"Store ready-to-feed formula at room temperature for up to 4 hours."

"Warm the battle of formula by immersing it in a container of warm tap water."

"Keep open cans of concentrated formula uncovered and refrigerated."

"Discard any formula left in the bottle within 2 hours after beginning feeding”

Answer and Explanation

The Correct Answer is D

Rationale:

A. "Store ready-to-feed formula at room temperature for up to 4 hours.": Ready-to-feed formula should be used promptly or refrigerated if not used immediately. Leaving it at room temperature for up to 4 hours increases the risk of bacterial growth and contamination.

B. "Warm the bottle of formula by immersing it in a container of warm tap water.": This is a safe and recommended method to gently warm formula without overheating or creating hot spots that could burn the infant’s mouth.

C. "Keep open cans of concentrated formula uncovered and refrigerated.": Open cans of concentrated formula should always be covered to prevent contamination and should be refrigerated promptly after opening.

D. "Discard any formula left in the bottle within 2 hours after beginning feeding.": Formula left in the bottle after feeding should be discarded within 1 to 2 hours to prevent bacterial growth that can cause illness in the infant. This practice helps ensure feeding safety.

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Correct Answer is C

Explanation

Rationale:

A. "Swaddle the newborn before securing the clips.": Swaddling before placing the newborn in the car seat is unsafe because it can prevent proper restraint and increase the risk of injury during a crash. The newborn should be secured directly by the harness straps.

B. "Add a soft head support in the car seat if necessary.": Adding aftermarket soft head supports can interfere with the car seat’s harness system and safety performance. Only manufacturer-approved accessories should be used.

C. "Secure the straps across the newborn's chest at the level of their armpits.": The harness straps should be positioned at or just below the newborn’s shoulders, with the chest clip placed at the armpit level to ensure optimal restraint and prevent movement during sudden stops.

D. "Ensure that the car seat is positioned at a 90 degree incline.": The car seat should be reclined at approximately a 45-degree angle to prevent the newborn’s head from falling forward and obstructing the airway during travel.

A. Hypertension B. Headache C. Tinnitus D. Urticaria

Correct Answer is D

Explanation

Rationale:

A. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.

B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.

C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.

D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.

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A nurse is reinforcing teaching with a caregiver about how to safely prepare formula for their 3-day-old newborn. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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