A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take?
Offer to take the newborn to the nursery to finish his feeding.
Insist that the mother pick up the newborn to feed him.
Demonstrate how to hold the newborn and allow the client to practice.
Persuade the client to breastfeed the newborn to promote bonding.
The Correct Answer is A
It is important to ensure the safety of the newborn, and in this situation, the adolescent mother is putting the newborn at risk by leaving him unattended while feeding. Offering to take the newborn to the nursery allows him to finish feeding in a safe environment while also allowing the nurse to assess his feeding and ensure he is receiving adequate nutrition. It is important to provide education to the mother on safe feeding practices, but at this moment, ensuring the safety of the newborn is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should inform the client that an amniocentesis is a diagnostic test used to identify genetic or congenital disorders and is not performed solely to determine the sex of the fetus. Therefore, the appropriate response by the nurse would be, "This procedure determines if your baby has genetic or congenital disorders."
Amniocentesis is an invasive procedure that carries a small risk of miscarriage, and it is typically offered to women who are at increased risk of having a baby with a genetic or chromosomal disorder. It is not routinely performed solely for the purpose of determining the sex of the fetus. Therefore, the nurse should educate the client about the purpose and risks of the procedure before the client decides to proceed with the test.
Correct Answer is C
Explanation
Magnesium sulfate is a medication used to prevent and treat seizures in clients with preeclampsia and eclampsia. It is also used to stop preterm labor. However, magnesium sulfate can cause a variety of side effects, including decreased reflexes, which can be a sign of magnesium toxicity. Therefore, it is important for the nurse to monitor the client for signs of toxicity.
Option A is incorrect because a decrease in the frequency of contractions is a desired effect of magnesium sulfate when it is used to stop preterm labor.
Option B is also incorrect because although a blood pressure of 150/100 mm Hg is elevated, it is not an unexpected finding in a client with preeclampsia, and it may actually be considered an improvement if the client's blood pressure was previously higher.
Option D is incorrect because a urinary output of 35 mL/hr is within the normal range for an adult.
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