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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 A

Explanation

Choice A rationale

A pudendal block is a type of anesthesia that results in a loss of sensation confined to the vagina and perineum. It’s often used during the second stage of labor or for episiotomy repair.

Choice B rationale

A paracervical block provides anesthesia to the cervix and the lower part of the uterus, but it does not specifically target the vagina and perineum.

Choice C rationale

An epidural block provides a band of numbness from the bellybutton to the upper legs, allowing the patient to be awake and alert throughout labor. It’s not confined to the vagina and perineum.

Choice D rationale

A saddle block is a type of spinal anesthesia that numbs the inner thighs, buttocks, and area around the rectum (the “saddle” area), but it’s not confined to the vagina and perineum.

A. Hegar’s sign. B. Breast tenderness. C. Amenorrhea. D. Morning sickness.

Correct Answer is C

Explanation

Choice C rationale

Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.

Choice A rationale

Hegar’s sign is a physical examination finding that can be indicative of pregnancy. However, it is not typically used as the primary indicator of pregnancy because it requires a pelvic examination and is less reliable than other signs such as amenorrhea.

Choice B rationale

While breast tenderness can be a symptom of early pregnancy, it is not the most reliable indicator. Many other conditions or factors, such as hormonal fluctuations related to the menstrual cycle, can also cause breast tenderness.

Choice D rationale

Morning sickness, characterized by nausea and vomiting, is a common symptom of early pregnancy. However, not all pregnant women experience morning sickness, and it can also be caused by other conditions. Therefore, it is not the most reliable indicator of pregnancy.

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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

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

Correct Answer is A

Explanation

A client informs the nurse that she believes she is pregnant. Which sign or symptom is the best indicator that the client is pregnant?

Correct Answer is C

Explanation

One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?

A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure.Which assessment action should the nurse prioritize?

A postpartum client who is formula-feeding her new baby inquires about when she should expect her menstruation to resume.What should the nurse inform the client?

A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit.What complication should the nurse prioritize during the client’s assessment?

The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?

A neonate, who is one day old, develops a cephalhematoma.Which common complication should the nurse assess this neonate for?

The nurse is caring for a client who delivered 6 hours ago.The client’s uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?

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?