A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?
"I will keep my baby's head elevated while he is feeding.”
"I will allow my baby to burp several times during each feeding.”
"I will tip the nipple so air is present as my baby sucks.”
"My baby will have soft, formed yellow stools.”
The Correct Answer is C
The correct answer is choice C: "I will tip the nipple so air is present as my baby sucks.”
Choice A rationale:
The parent's statement in choice A, "I will keep my baby's head elevated while he is feeding,” indicates an understanding of proper bottle feeding techniques. Keeping the baby's head slightly elevated can help prevent choking and aspiration during feedings. This is a correct statement, and no further instruction is needed in this regard.
Choice B rationale:
The parent's statement in choice B, "I will allow my baby to burp several times during each feeding,” also demonstrates knowledge of appropriate bottle feeding practices. Burping the baby during and after feedings helps release swallowed air, reducing the likelihood of excessive gas and discomfort. This statement is correct, and no additional instruction is required.
Choice C rationale:
Choice C is the incorrect statement because tipping the nipple to introduce air while the baby sucks is not a recommended practice. In fact, it can lead to an increased intake of air, potentially causing gas, discomfort, and colic in the baby. Therefore, further instruction is needed to correct this misconception.
Choice D Rationale:
Choice D is not directly related to the need for further instruction in bottle feeding techniques and is not addressed in the explanation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Preparing for an amnioinfusion is not the first-line action. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Choice B reason:
Administering oxygen is a subsequent measure if initial interventions like repositioning do not improve the FHR. Oxygen is typically given at 8-10 L/min via a nonrebreather mask to increase fetal oxygenation.
Choice C reason:
Discontinuing oxytocin is important if the cause of decelerations is uterine hyperstimulation. However, repositioning the client should precede this action to quickly address potential umbilical cord compression.
Choice D reason:
This is the first action to take because it can quickly alleviate potential compression of the umbilical cord, which is often the cause of variable decelerations. It may be considered if decelerations do not resolve with initial measures such as maternal repositioning.
Correct Answer is A
Explanation
Choice A rationale:
The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.
Choice B rationale:
Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.
Choice C rationale:
Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.
Choice D rationale:
Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.
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