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

Answer and Explanation

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.

Breastfeeding techniques and Burping Positions. | Download Scientific Diagram

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Discuss options for intrauterine surgical correction of congenital defects:At this point, the AFP result is only an indicator, not a diagnosis. The client has not undergone sufficient diagnostic evaluation (such as ultrasound) to confirm any congenital defect that would warrant intrauterine surgery. Treatment options can only be discussed once a definitive diagnosis has been made.

B. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated:While a repeat AFP test could be done in some cases to rule out lab error or confirm the result, this is not typically the immediate next step. An ultrasound provides more definitive and comprehensive information than simply repeating the AFP test.

C. Reassure the client that the AFP results are likely to be a false reading:Providing false reassurance may lead to misunderstandings. While false positives can happen, it's crucial to follow up with further assessments to ensure the accuracy of the results.

D. Explain that a sonogram should be scheduled for definitive results:An elevated AFP level is a screening test, not a definitive diagnosis. A sonogram (ultrasound) is the next step to obtain more detailed information about the fetus. Ultrasound can help assess for neural tube defects, confirm gestational age, and check for other anomalies that could explain the elevated AFP levels. This provides the most accurate and non-invasive method for evaluating potential fetal abnormalities.

A. Request a return demonstration of a diaper change B. Evaluate infant feeding techniques prior to discharge C. Provide the results of the infant's hearing test to the parents. D. Ensure that they have the pediatric clinic's phone number

Correct Answer is B

Explanation

A. Request a return demonstration of a diaper change:While it's useful for parents to know how to change a diaper, feeding is more critical for the infant’s health and development in the early days.

B. Evaluate infant feeding techniques prior to discharge:Ensuring that the parents understand how to properly feed their newborn is crucial. Proper feeding techniques are essential for the infant's nutrition, growth, and development. Issues with feeding can lead to dehydration, weight loss, and other health problems. Therefore, this is the most important intervention.

C. Provide the results of the infant's hearing test to the parents:Sharing the results of the hearing test is important, but it is less immediate compared to ensuring that the infant is properly fed.

D. Ensure that they have the pediatric clinic's phone number:
While it is important for parents to have contact information for follow-up care, it is secondary to ensuring they can feed their baby properly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Correct Answer is D

Explanation

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

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?