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

Answer and Explanation

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.

Breastfeeding techniques and Burping Positions. | Download Scientific Diagram

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.

B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.

C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.

D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.

A. Request a return demonstration of a diaper change B. Evaluate infant feeding techniques prior to discharge C. Provide the results of the infant's hearing test to the parents. D. Ensure that they have the pediatric clinic's phone number

Correct Answer is B

Explanation

A. Request a return demonstration of a diaper change:While it's useful for parents to know how to change a diaper, feeding is more critical for the infant’s health and development in the early days.

B. Evaluate infant feeding techniques prior to discharge:Ensuring that the parents understand how to properly feed their newborn is crucial. Proper feeding techniques are essential for the infant's nutrition, growth, and development. Issues with feeding can lead to dehydration, weight loss, and other health problems. Therefore, this is the most important intervention.

C. Provide the results of the infant's hearing test to the parents:Sharing the results of the hearing test is important, but it is less immediate compared to ensuring that the infant is properly fed.

D. Ensure that they have the pediatric clinic's phone number:
While it is important for parents to have contact information for follow-up care, it is secondary to ensuring they can feed their baby properly.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is A

Explanation

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?