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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 B

Explanation

Choice A rationale

While notifying the charge nurse about the patient’s condition is an important step, it is not the immediate action that should be taken in this situation. The priority is to address the tachysystolic or tetanic contractions and variable fetal heart decelerations, which are signs of potential fetal distress.

Choice B rationale

Discontinuing the oxytocin infusion is the correct action. Oxytocin is a hormone that stimulates uterine contractions during labor. If a patient begins to experience tachysystolic or tetanic contractions, which are excessively frequent or prolonged contractions, it could lead to fetal distress. Discontinuing the oxytocin can help reduce the frequency and intensity of the contractions.

Choice C rationale

Reducing the rate of the oxytocin infusion may not be sufficient in this situation. Tachysystolic or tetanic contractions with variable fetal heart decelerations are serious signs that require immediate action. Simply reducing the rate of the infusion may not alleviate these symptoms quickly enough.

Choice D rationale

Adjusting the position of the fetal monitor transducers would not address the issue of tachysystolic or tetanic contractions. While it is important to ensure accurate monitoring of the fetus, the priority in this situation is to address the potentially harmful contractions.

A. Calcium. B. Folic acid. C. Vitamin D. D. Iron.

Correct Answer is B

Explanation

Choice A rationale

Calcium is essential for the development of fetal bones and teeth, but it is not specifically linked to preventing neural tube defects like anencephaly.

Choice B rationale

Folic acid is vital for preventing neural tube defects, including anencephaly. It’s recommended for women of childbearing age and especially during the early stages of pregnancy.

Choice C rationale

Vitamin D is important for bone health, but its primary function is not directly related to preventing neural tube defects like anencephaly.

Choice D rationale

Iron is crucial for preventing anemia in pregnancy, supporting increased blood volume. However, it is not directly associated with preventing neural tube defects.

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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

A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations.What should the nurse do next?

Correct Answer is B

Explanation

The nurse is providing preconception counseling.Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

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?