A nurse is observing an adolescent client who is offering her newborn a botle 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 C
This option respects the mother's wishes of not wanting to hold the newborn while also allowing the nurse to provide education on safe and appropriate feeding positions. It also gives the mother the opportunity to learn and practice holding the newborn in a safe way.
Option a, offering to take the newborn to the nursery, may not be necessary as the mother is already offering the baby a botle.
Option b, insisting that the mother pick up the newborn, would not be respectful of her wishes and could potentially damage the trust and rapport between the mother and nurse.
Option d, persuading the client to breastfeed, may not be appropriate or feasible in this situation as it may not be the mother's preferred feeding method and may not address the immediate concern of the newborn being too tired to be held.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A is incorrect because medroxyprogesterone injections are typically given every three months, not every eight weeks.
Choice B is incorrect; the client will receive only one shot at a time, not two.
Choice C is correct; clients are advised to increase their calcium intake while on medroxyprogesterone to help prevent bone density loss, which can be a side effect of the medication.
Choice D is incorrect; spotting is a common side effect of medroxyprogesterone, and clients are usually advised to continue the medication despite this unless advised otherwise by their healthcare provider.
Correct Answer is C
Explanation
Pregnant clients with HIV require comprehensive care during pregnancy, delivery, and postpartum periods to prevent transmission of HIV to the newborn. Bathing the newborn before initiating skin-to-skin contact is a recommended action to reduce the risk of HIV transmission from mother to child. This practice helps to remove any maternal blood or other bodily fluids from the newborn's skin, which may contain the virus. Therefore, the nurse should instruct the client to bathe the newborn before initiating skin-to-skin contact.
Antiretroviral medications are usually continued throughout pregnancy and during labor and delivery to decrease the risk of transmission to the newborn. Therefore, the nurse should not instruct the client to stop taking antiretroviral medications at 32 weeks of gestation, as mentioned in option a.
Fetal scalp electrode is a device that ataches to the baby's scalp to monitor the fetal heart rate. This device can cause small cuts or abrasions on the baby's scalp, which may increase the risk of HIV transmission.
Therefore, its use should be avoided in clients with HIV. Therefore, option b is not a recommended action.
Administering pneumococcal immunization to the newborn within 4 hours following birth is not a recommended action in the plan of care for a client who is pregnant and has HIV. Pneumococcal immunization is not indicated for newborns immediately after birth. Therefore, option d is not a recommended action.
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