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After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper.
As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

Clean up the spit-up and assist the mother with the diaper change.

Position the newborn on the side and suction the mouth and nares with a bulb syringe.

Position the newborn with the head lower than the feet.

Sit the newborn upright and burp by gently rubbing or patting the upper back.

Answer and Explanation

The Correct Answer is D

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

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Correct Answer is C

Explanation

Choice A rationale

While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.

Choice B rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.

Choice C rationale

Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.

A. Call the healthcare provider. B. Encourage the client to void. C. Administer ibuprofen 800 mg by mouth. D. Increase the intravenous fluid to 150 mL/hour.

Correct Answer is B

Explanation

Choice A rationale

While notifying the healthcare provider is important, it is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder that could be displacing the uterus.

Choice B rationale

Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.

Choice C rationale

Administering ibuprofen can help with cramping, but it does not address the immediate issue of a potentially full bladder displacing the uterus.

Choice D rationale

Increasing the intravenous fluid rate is not the first action to take. The nurse should first address the immediate issue of a potentially full bladder displacing the uterus.

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After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Correct Answer is C

Explanation

A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus.What action should the nurse take first?

Correct Answer is B

Explanation

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After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper.
As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?