A nurse is assisting a postpartum client who is breastfeeding her newborn for the first time 2 hr after birth.
Which of the following actions should the nurse take? (Select all that apply.)
The nurse should assess for proper latch-on technique and encourage skin-to-skin contact between mother and infant. These actions promote successful breastfeeding and bonding.
Encourage skin-to-skin contact between mother and infant
Limit feeding time to 10 min per breast
Instruct client to offer both breasts at each feeding
Advise client to feed infant every 2 to 3 hr.
Correct Answer : A,B
The nurse should assess for proper latch-on technique and encourage skin-to-skin contact between mother and infant.
These actions promote successful breastfeeding and bonding.
Choice C is wrong because limiting feeding time to 10 min per breast can interfere with the infant’s intake of hindmilk, which is rich in fat and calories. The infant should be allowed to nurse until satisfied, which may take longer than 10 min per breast.
Choice D is wrong because instructing the client to offer both breasts at each feeding can lead to nipple soreness and engorgement. The client should offer one breast until it is emptied, then switch to the other breast if the infant is still hungry.
Choice E is wrong because advising the client to feed the infant every 2 to 3 hr can disrupt the infant’s natural feeding cues and rhythms. The client should feed the infant on demand, which may be more or less frequent than every 2 to 3 hr.
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Correct Answer is B
Explanation
Use an oral syringe to squirt the medication into the side of the mouth.
This is because an oral syringe allows the nurse to measure the exact dose of the medication and deliver it slowly and safely into the infant’s mouth, avoiding choking or aspiration.
The other choices are wrong for the following reasons:
• Choice A) Mixing the medication with formula in a bottle can alter the taste and effectiveness of the medication, and also make it difficult to ensure that the infant receives the full dose.
• Choice C) Placing the medication on a pacifier can cause the infant to spit out the pacifier or the medication, and also increase the risk of infection from contaminated pacifiers.
• Choice D) Dipping a cotton swab in the medication and rubbing it on the gums can irritate the oral mucosa and cause pain or bleeding, and also waste some of the medication on the swab.
Correct Answer is B
Explanation
Runs with a wide stance.This indicates normal gross motor development for an 18-month-old toddler.Gross motor skills are the abilities to use large muscles for movements such as walking, running, jumping, and climbing.
Choice A is wrong because walking up and down stairs with assistance is a skill that most toddlers can do by 24 months.
Choice C is wrong because kicking a ball forward without falling is a skill that most toddlers can do by 24 months.
Choice D is wrong because jumping in place with both feet is a skill that most toddlers can do by 30 months.
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