A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse's best response?
- A. Formula may turn sour after it is opened.'
- B. Bacteria can grow rapidly in warm milk.'
- C. Formula loses some nutritional value once it is opened.'
- D. This makes it easier to keep track of how much the baby is taking.'
Correct Answer: B
Rationale: The correct answer is B because bacteria can grow rapidly in warm milk, increasing the risk of contamination and illness for the baby. Opening a new bottle for each feeding ensures the formula is fresh and safe for consumption. Choice A is incorrect because formula does not necessarily turn sour immediately after opening. Choice C is incorrect because nutritional value does not significantly decrease after opening. Choice D is incorrect as it does not address the health and safety concerns associated with bacteria growth in opened formula.
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In which condition is breastfeeding contraindicated?
- A. Triplet birth
- B. Flat or inverted nipples
- C. Human immunodeficiency virus infection
- D. Inactive, previously treated tuberculosis
Correct Answer: C
Rationale: The correct answer is C: Human immunodeficiency virus infection. Breastfeeding is contraindicated in this condition due to the risk of vertical transmission of the virus to the infant through breast milk. HIV can be present in breast milk, increasing the risk of infection to the baby. This is supported by guidelines from organizations such as WHO.
Choices A, B, and D are incorrect:
A: Triplet birth is not a contraindication for breastfeeding; it may require additional support but is not a direct contraindication.
B: Flat or inverted nipples may pose initial challenges but can be addressed with proper latch techniques or the use of aids like nipple shields.
D: Inactive, previously treated tuberculosis does not contraindicate breastfeeding as long as the mother has completed treatment and is not actively infectious.
The nurse knows that during the motoric process, the newborn will be rated poorly if they do what?
- A. They have good reflexes.
- B. They have hyper- or hypotonic movements.
- C. They have good head control.
- D. They have moderate activity levels.
Correct Answer: B
Rationale: Hyper- or hypotonic movements indicate poor motoric development.
What assessment findings indicate abnormal transition in a neonate? Select all that apply.
- A. prolonged apneic episodes
- B. marked pallor
- C. excessive oral secretions
- D. crackles upon auscultation
Correct Answer: C
Rationale: Abnormal transition signs include prolonged apnea, marked pallor, excessive secretions, and crackles.
An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?
- A. Call the hospital chaplain to visit the parents.
- B. Obtain informed consent for emergency surgery.
- C. Prepare the parents for how the infant will look.
- D. Show the parents proper gowning and gloving.
Correct Answer: C
Rationale: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.
The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity?
- A. The infant's arms and legs are extended.
- B. There is some peeling and cracking of the skin.
- C. There are few rugae on the scrotum and the testes are high in the scrotum.
- D. The arm can be positioned with the elbow beyond the midline of the chest.
Correct Answer: B
Rationale: The correct answer is B because peeling and cracking of the skin, known as desquamation, is characteristic of a newborn born at term or post-term. This indicates the skin has been in contact with amniotic fluid for an extended period, typical of a more mature gestational age. Choices A, C, and D are incorrect as they do not specifically indicate gestational maturity. Arms and legs extended (A) can be seen in preterm infants. Few rugae on the scrotum and high testes (C) can be normal variations in newborns. The arm positioning (D) does not provide a direct indicator of gestational age.