After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
Place the newborn in a position with the head lower than the feet.
Turn the newborn to the side and bulb suction the mouth and nares.
Wipe away the spit-up and assist the mother with the diaper change
Sit the newborn upright and burp by rubbing or patting the upper back
The Correct Answer is D
A. Place the newborn in a position with the head lower than the feet:
This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.
B. Turn the newborn to the side and bulb suction the mouth and nares:
Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.
C. Wipe away the spit-up and assist the mother with the diaper change:
Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.
D. Sit the newborn upright and burp by rubbing or patting the upper back:
This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Epidural block: Epidural anesthesia is a regional anesthesia that blocks sensations in a specific region of the body. It is commonly used in labor and delivery to provide pain relief by injecting anesthetic medication into the epidural space, numbing the lower half of the body.
B. Saddle block: A saddle block, also known as a subarachnoid block, is a type of spinal anesthesia. It involves injecting anesthetic medication into the subarachnoid space, providing numbness to the lower half of the body, including the perineum.
C. Paracervical block: A paracervical block involves injecting a local anesthetic around the cervix. It is used to provide pain relief during certain medical procedures, such as cervical dilation or biopsy. It does not provide anesthesia to the entire perineum.
D. Pudendal block: A pudendal block involves injecting a local anesthetic into the pudendal nerve, which supplies sensation to the perineum. It is often used during the second stage of labor to provide localized pain relief during the delivery of the baby's head.
Correct Answer is A
Explanation
A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.
B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.
C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.
D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.
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