A nurse is teaching the guardian of a newborn about formula feeding. Which of the following instructions should the nurse include?

Boil bottle rings and nipples for 10 min to ensure sanitization.

Keep the newborn on a strict 3 hr feeding schedule.

Use bottles of refrigerated formula within 48 hr.

Place the newborn on their abdomen for 30 min following each feeding.

Answer and Explanation

The Correct Answer is C

A. Boil bottle rings and nipples for 10 min to ensure sanitization. Boiling for 10 minutes is excessive and can damage bottle parts. A boil time of 5 minutes is typically sufficient for sanitizing feeding equipment before first use.
B. Keep the newborn on a strict 3 hr feeding schedule. Newborns should be fed on demand, which may be more or less frequently than every 3 hours. Hunger cues should guide feeding to promote healthy growth and bonding.
C. Use bottles of refrigerated formula within 48 hr. Prepared formula should be refrigerated and used within 48 hours to ensure safety and prevent bacterial growth. This is a safe practice when storing formula that has not been fed to the infant.
D. Place the newborn on their abdomen for 30 min following each feeding. Placing a newborn on the abdomen increases the risk of sudden infant death syndrome (SIDS). Infants should always be placed on their backs to sleep.

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Correct Answer is C

Explanation

A. "I can adjust the time and schedule for when it's convenient for you." While the nurse should respect the client’s preferences, medication timing must follow facility policy and the prescribed schedule, especially for time-sensitive drugs like vancomycin.
B. "I can infuse the medication at a faster rate." Vancomycin must be infused slowly (typically over at least 60 minutes) to prevent Red Man Syndrome and other complications. Increasing the rate can be dangerous and is not appropriate.
C. “I have up to 2 hours after the usual scheduled time to give you this medication." This aligns with standard medication administration policies, which generally allow for a 1-hour window before or after the scheduled time for most medications (and up to 2 hours depending on policy and the medication). This response shows appropriate clinical judgment and adherence to safe timing.
D. “I can start the medication 30 minutes earlier." While this may be acceptable in some cases, it doesn't fully address the client’s request for 2 hours earlier, nor does it reflect the standard administration window as accurately as option C.

A. Bradypnea B. Distended neck veins C. Weight loss D. Bradycardia

Correct Answer is B

Explanation

A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.

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A nurse is teaching the guardian of a newborn about formula feeding. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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