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 ["E"]
Explanation
A. Place client in a negative pressure room: Negative pressure rooms are typically used for airborne precautions, not for preventing the transmission of HIV, which primarily requires standard precautions.
B. Implement droplet precautions: HIV does not spread through respiratory droplets. Droplet precautions are for diseases like influenza or meningitis that spread through respiratory droplets, not for HIV.
C. Encourage the mother to bottle-feed: This recommendation can vary based on specific circumstances. In many developed countries, the recommendation is for HIV-positive mothers to avoid breastfeeding to reduce the risk of transmitting HIV to the infant. However, this decision should be discussed with healthcare providers and based on individual circumstances.
D. Give antiviral medication intravenously: Antiretroviral medications are used to manage HIV. However, the method of administration and specific medications depend on the client's condition and the stage of pregnancy. Intravenous administration might not be the standard for HIV management during labor.
E. Use standard precautions: Standard precautions are the most appropriate approach. These include wearing gloves, practicing good hand hygiene, and using protective barriers as needed to prevent contact with blood and body fluids, which is the primary mode of HIV transmission.
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.
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