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 A
Explanation
A. Obtain blood and urine for prenatal screens.
This choice is important because it allows the nurse to assess the client's overall health, screen for infections, and identify any potential risks or complications that may impact the pregnancy.
B. Explain common complications of pregnancy.
While educating the client about common complications is valuable, it may not address the immediate need to screen for specific infections or assess the client's current health status. This information can be covered during prenatal education sessions.
C. Obtain baseline blood pressure and weight.
This is a routine part of prenatal care and is important for monitoring the client's health throughout pregnancy. However, if the client has a history of syphilis, obtaining specific prenatal screens (including for syphilis) would be a more targeted and immediate action.
D. Schedule prenatal visits to occur monthly.
Scheduling regular prenatal visits is essential for monitoring the progression of the pregnancy. However, addressing the specific health concerns and obtaining necessary screens take precedence during the initial visit, especially considering the client's history of syphilis.
Correct Answer is C
Explanation
A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.
B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.
C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.
D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.
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