A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

"Your baby needs to suck on a pacifier."

"Swaddling your baby snugly in a blanket might help soothe her."

"Breastfed babies are usually fussy from swallowing too much air during feedings."

"Breastfed babies often need to be supplemented with formula."

Answer and Explanation

The Correct Answer is B

A. "Your baby needs to suck on a pacifier" is not necessarily the best advice for this situation. While pacifiers can help some babies self-soothe, crying is often a sign of an unmet need, and further assessment is needed to determine the cause of the crying. Offering a pacifier without addressing other potential causes might overlook the root issue.

B. "Swaddling your baby snugly in a blanket might help soothe her" is correct. Swaddling can help calm a newborn by providing a sense of security and warmth, mimicking the conditions of the womb. It is a common technique used to soothe babies.

C. "Breastfed babies are usually fussy from swallowing too much air during feedings" is incorrect. While some babies may have mild gas or discomfort from swallowing air, excessive crying is not typically due to this alone, especially if the baby has been fed properly and burped.

D. "Breastfed babies often need to be supplemented with formula" is not appropriate. While some breastfeeding difficulties can occur, advising formula supplementation without further investigation could undermine the breastfeeding process and should only be suggested after careful assessment and if truly necessary.

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Correct Answer is A

Explanation

A. "I should keep my baby rear-facing in the car seat until she is 2 years old.": This is correct. The American Academy of Pediatrics recommends that infants and toddlers remain in a rear-facing car seat until they are at least 2 years old or until they reach the height and weight limits specified by the car seat manufacturer. Rear-facing provides the best protection for the baby's head, neck, and spine in the event of an accident.

B. "I should position the car seat's retainer clip at the level of my baby's belly button.": This is incorrect. The retainer clip should be positioned at armpit level, not at the belly button. This ensures the harness fits snugly and securely around the baby.

C. "I should enable the airbag when my baby is in the front seat of the car.": This is incorrect. Airbags should never be enabled when a baby is sitting in the front seat, as they can cause injury in the event of a collision. The baby should always be seated in the back seat of the car, as it is the safest location.

D. "I should place my baby in the car seat at a 90-degree angle.": This is incorrect. The car seat should be reclined at an angle of approximately 45 degrees to ensure the baby’s head does not fall forward, which could compromise breathing. A 90-degree angle is too upright and may be unsafe for a newborn.

A. Contact the client's caregiver to discuss the client's comment. B. Review the medical record to see if the client has reported abuse in the past. C. Report the suspected abuse to the nurse manager. D. Restrict family members from visiting with the client.

Correct Answer is B

Explanation

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

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