Nokea
The nurse is preparing a new mother and newborn for discharge. Which statement indicates learning has occurred in the mother?
- A. I will feed my newborn every 3 hours while awake.'
- B. I will exclusively breastfeed my newborn every 2 to 3 hours.'
- C. I will supplement feedings with formula until my breast milk comes in.'
- D. Iron-fortified formula will be needed after my newborn is 6 months of age.'
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of the importance of exclusive breastfeeding every 2 to 3 hours. This statement shows the mother has learned about the recommended feeding schedule for newborns and the benefits of exclusive breastfeeding. Choice A is incorrect because feeding every 3 hours does not emphasize exclusive breastfeeding. Choice C is incorrect as supplementing with formula can interfere with establishing breastfeeding. Choice D is incorrect because iron-fortified formula is not typically needed if the baby is breastfed exclusively for the first 6 months.
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The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?
- A. Draws legs up tight against the lower abdomen
- B. Extends legs straight against the pressure
- C. Makes stepping actions with both feet
- D. Toes curl in then fan outward symmetrically
Correct Answer: C
Rationale: The stepping reflex occurs when the infant is held upright and his or her feet brush a horizontal surface distal to the feet. Drawing the legs up tight against the lower abdomen would be an abnormal response. Extending the legs against pressure is a positive magnet reflex. Curling the toes in, then fanning them outward, is a positive Babinski reflex.
The nurse provides discharge instructions to a parent about umbilical cord care. What statement by the parent indicates effective health teaching?
- A. My child can have a tub bath every day.'
- B. I will clean the stump with antiseptics daily.'
- C. Water and soap can be used if the stump is dirty.'
- D. I need to apply an antibiotic ointment every day.'
Correct Answer: C
Rationale: Step 1: Using water and soap if the stump is dirty is the correct method for umbilical cord care as per current guidelines.
Step 2: Soap and water help prevent infection without disrupting the natural healing process.
Step 3: Daily tub baths or using antiseptics or antibiotic ointments can be harmful by interfering with healing.
Step 4: Therefore, choice C is the most appropriate and effective method for umbilical cord care.
When giving a newborn a bath, what is a concern for the nurse (or caregiver)?
- A. hyperbilirubinemia
- B. hypoglycemia
- C. thermoregulation
- D. contact dermatitis
Correct Answer: C
Rationale: Maintaining thermoregulation is critical during bathing to prevent hypothermia.
Which of the following is an important consideration in positioning a newborn for breastfeeding?
- A. Placing the infant at nipple level facing the breast.
- B. Keeping the infant's head slightly lower than the body.
- C. Using the forefinger and middle finger to support the breast.
- D. Limiting the amount of areola the infant takes into the mouth.
Correct Answer: A
Rationale: The correct answer, A, is important because it ensures proper alignment for effective breastfeeding. Placing the infant at nipple level facing the breast helps the baby latch on correctly, promoting optimal milk transfer. Choice B is incorrect as the infant's head should be in line with the body to prevent swallowing issues. Choice C is incorrect because the fingers should support the breast underneath, not on top. Choice D is also incorrect as the baby should take in a sufficient amount of areola for a deep latch.
The nurse is assigned to the room of a 15-year-old person who gave birth to a newborn 72 hours ago. Why is this newborn a perfect candidate for the Brazelton assessment?
- A. This parent-newborn couplet is at risk for delayed attachment.
- B. The newborn is likely going home soon.
- C. The EHR is prompting her to do so.
- D. The infant is likely withdrawing from a substance.
Correct Answer: A
Rationale: Delayed attachment may occur in younger parents, making the Brazelton assessment valuable for evaluating bonding.