Nokea
A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to
- A. tell the patient to wear a bra at all times to provide more support to breast tissue.
- B. have the patient put the infant to her breast more frequently.
- C. place ice packs on breast tissue after infant feeding.
- D. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.
Correct Answer: B
Rationale: Step 1: Breast tenderness and fullness between feedings indicate engorgement, a common issue in breastfeeding mothers.
Step 2: Putting the infant to the breast more frequently helps empty the breast and prevents engorgement.
Step 3: Regular feeding stimulates milk production and prevents discomfort.
Step 4: This approach is effective in addressing the underlying issue of engorgement.
Summary:
A: Wearing a bra at all times may not address the root cause of engorgement.
C: Ice packs can provide temporary relief but do not prevent engorgement.
D: Normalizing the issue without providing a solution does not address the discomfort.
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What steps are included in the QSEN steps for rewarming a neonate at risk for cold stress? Select all that apply.
- A. placing the neonate under the radiant warmer
- B. putting a pulse oximeter on the neonate
- C. assessing a blood glucose level
- D. calling the NICU team for assessment
Correct Answer: A
Rationale: Steps include placing the neonate under a radiant warmer and assessing blood glucose levels.
Which statement is the most accurate regarding suctioning of the oral and nasal passages of a newborn?
- A. The bulb syringe should be compressed after it is inserted into the baby's nose to suction.
- B. Suction the nose and then the mouth of the newborn to prevent aspiration.
- C. Saline should be placed in the baby's nose and mouth prior to suctioning.
- D. Place the bulb syringe on the side of the infant's cheek while suctioning the mouth.
Correct Answer: B
Rationale: The correct answer is B: Suction the nose and then the mouth of the newborn to prevent aspiration. This is the most accurate statement because suctioning the nose first prevents any mucus or secretions from being pushed into the mouth during suctioning. Aspiration can occur if the baby inhales any secretions. Suctioning the mouth after the nose ensures that any remaining secretions are cleared.
Choice A is incorrect because compressing the bulb syringe after insertion can cause trauma to the delicate nasal passages. Choice C is incorrect as using saline before suctioning is not necessary and may increase the risk of aspiration. Choice D is incorrect as placing the bulb syringe on the side of the infant's cheek is not an effective method for suctioning the mouth or nose.
Which baby is at highest risk of skin infection upon discharge?
- A. Newborn with scabs forming over heels where blood has been drawn
- B. Newborn with a new circumcision
- C. Newborn with jaundice
- D. Newborn with milia
Correct Answer: B
Rationale: The correct answer is B, a newborn with a new circumcision, as this procedure involves an incision, making the baby more susceptible to skin infections. Circumcision wounds need proper care to prevent infection.
Choice A is incorrect because scabs forming over heels where blood has been drawn do not necessarily indicate a higher risk of skin infection. Choice C, a newborn with jaundice, is incorrect as jaundice affects the liver and does not directly increase the risk of skin infection. Choice D, a newborn with milia, is incorrect because milia are harmless and do not increase the risk of skin infection.
Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma?
- A. Assess the nipples before each feeding.
- B. Limit the feeding time to less than 5 minutes.
- C. Wash the nipples daily with mild soap and water.
- D. Position the infant so the nipple is far back in the mouth.
Correct Answer: D
Rationale: The correct answer is D: Position the infant so the nipple is far back in the mouth. This technique helps prevent nipple trauma by ensuring that the baby latches onto the breast correctly, with a deep latch that prevents excessive pressure and friction on the nipple. By positioning the nipple far back in the baby's mouth, the baby can effectively suckle and draw milk without causing damage to the nipple.
Choice A is incorrect because simply assessing the nipples before each feeding does not actively prevent trauma. Choice B is incorrect as limiting feeding time to less than 5 minutes can lead to inadequate milk transfer and potential nipple trauma due to improper latch. Choice C is incorrect as washing the nipples daily with soap and water can actually strip the skin of natural oils and increase the risk of dryness and cracking, leading to trauma.
An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score?
- A. 0115 to 0130
- B. 0200 to 0600
- C. 1400 to 1800
- D. 2000 to 2300
Correct Answer: B
Rationale: The correct answer is B (0200 to 0600) because the Ballard score is typically assessed within the first 12-24 hours of life. Given that the infant was born at 0105 hours, the nurse should plan on performing the assessment between 0200 to 0600. This time frame falls within the recommended window for assessing the Ballard score accurately. Choices A, C, and D are incorrect because they fall outside the optimal time range for conducting the assessment. Option A (0115 to 0130) is too soon after birth, and options C (1400 to 1800) and D (2000 to 2300) are too late for the initial assessment as per standard practice.