After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
Place the newborn in a position with the head lower than the feet.
Turn the newborn to the side and bulb suction the mouth and nares.
Wipe away the spit-up and assist the mother with the diaper change
Sit the newborn upright and burp by rubbing or patting the upper back
The Correct Answer is D
A. Place the newborn in a position with the head lower than the feet:
This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.
B. Turn the newborn to the side and bulb suction the mouth and nares:
Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.
C. Wipe away the spit-up and assist the mother with the diaper change:
Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.
D. Sit the newborn upright and burp by rubbing or patting the upper back:
This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Place the newborn in a position with the head lower than the feet:
This position might be used in cases of choking or difficulty breathing, but it's not typically the first response to spitting up.
B. Turn the newborn to the side and bulb suction the mouth and nares:
Suctioning might be necessary if there's difficulty breathing or if there's an excessive amount of mucus. However, for typical spit-up, this might be an unnecessary intervention.
C. Wipe away the spit-up and assist the mother with the diaper change:
Addressing the immediate concern by cleaning up and assisting with the diaper change is a reasonable first step, but it doesn't directly address the spit-up.
D. Sit the newborn upright and burp by rubbing or patting the upper back:
This is a common and appropriate action after feeding to help release any trapped air and prevent or alleviate spit-up.
Correct Answer is A
Explanation
A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.
B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.
C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.
D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.
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