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The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
- A. The client states that the pain has decreased.
- B. The nurse hears the baby swallow after each suck.
- C. The baby's jaws move up and down once every second.
- D. The baby's cheeks move in and out with each suck.
Correct Answer: C
Rationale: Rapid jaw movements without swallowing suggest ineffective feeding.
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The mother notes that her baby has a 'bulge' on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following?
- A. Molding of the baby's skull so that the baby could fit through her pelvis.
- B. Swelling of the tissues of the baby's head from the pressure of her pushing.
- C. The position that the baby took in her pelvis during the last trimester of her pregnancy.
- D. Small blood vessels that broke under the baby's scalp during birth.
Correct Answer: A
Rationale: Molding occurs due to passage through the birth canal.
The nurse is concerned that a bottle-fed baby may become obese because of which activity by the mother?
- A. She encourages the baby to finish the bottle at each feed.
- B. She feeds the baby every 3 to 4 hours.
- C. She feeds the baby a soy-based formula.
- D. She burps the baby every 1/2 to 1 ounce.
Correct Answer: A
Rationale: Overfeeding can contribute to obesity.
During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?
- A. Letting-go
- B. Taking-in
- C. Taking-on
- D. Taking-hold
Correct Answer: A
Rationale: The correct answer is A: Letting-go. During this phase, the mother transitions from idealized fantasies about her baby to accepting the reality of the infant. She lets go of unrealistic expectations and embraces the actual characteristics of her child. Choice B, Taking-in, refers to the mother focusing on her own needs post-birth. Choice C, Taking-on, involves the mother identifying with her new role. Choice D, Taking-hold, pertains to the mother forming a strong bond with the baby. However, none of these phases specifically address the process of relinquishing idealized fantasies and accepting the real baby like the Letting-go phase does.
A breastfeeding woman calls the pediatric nurse with the following complaint:"I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time?
- A. Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes.
- B. Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula.
- C. The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula.
- D. In addition to giving the baby formula, you should wear a surgical face mask when you are around him.
Correct Answer: C
Rationale: Breastfeeding provides antibodies to protect the baby.
The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
- A. Sitz baths four times a day
- B. Use of only warm water with the sitz baths
- C. Topical anesthetic spray after perineal care
- D. Ice pack to the perineum for the first 24 hours
Correct Answer: A
Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.