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 A

Explanation

Rationale:

A. Nurse addressing the client directly while the interpreter is present: This demonstrates culturally competent and client-centered care. Documenting that the nurse communicated directly with the client through a qualified interpreter shows appropriate use of interpretation services and respect for the client's autonomy.

B. Nurse asking the client for questions at the end of the instructions: While this is good practice, it does not specifically demonstrate that the client's language needs were addressed. Without interpreter documentation there’s no assurance the client understood the information.

C. Staff member serving as an interpreter for the client: Unless the staff member is a certified medical interpreter, using them for interpretation may result in miscommunication and is not best practice. Documentation should reflect use of trained professionals.

D. Family member acting as an interpreter for the client: Family members should not be used for interpretation due to risks of bias, inaccuracies, and privacy violations. Professional interpreters are necessary to ensure accurate, safe, and confidential communication.

A. Remove the client's dentures from their mouth before rigor mortis begins B. Turn on all the lights in the room before the family views the client's body. C. Ask the client's family about cultural or religious practices regarding postmortem care D. Position the client's bed flat without a pillow under their head.

Correct Answer is C

Explanation

Rationale:

A. Remove the client's dentures from their mouth before rigor mortis begins: Removing dentures is generally done after rigor mortis to maintain the natural appearance of the face for viewing. Premature removal can alter facial structure and affect family perceptions.

B. Turn on all the lights in the room before the family views the client's body: Bright lighting may be uncomfortable or overwhelming for grieving family members. Soft, gentle lighting is usually preferred to create a calm and respectful environment.

C. Ask the client's family about cultural or religious practices regarding postmortem care: Different cultures and religions have specific rituals and practices for caring for the deceased. Inquiring about these preferences ensures that the nurse respects the family’s beliefs and supports culturally sensitive care.

D. Position the client's bed flat without a pillow under their head: After death, the head of the bed should be slightly elevated (e.g., 15-30 degrees) to prevent blood from pooling in the face and causing discoloration, which can be distressing for the family.

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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

A nurse is reinforcing discharge instructions with a client who speaks a different language than the nurse. Which of the following actions should the nurse document in the client's medical record to ensure the language needs are met?

Correct Answer is A

Explanation

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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