The nurse is caring for a 1-day postpartum client that is breastfeeding a healthy full-term newborn. The client requests a bottle of formula and verbalizes that she does "not have any milk". What is the most appropriate response?
Explain what colostrum is and offer to assist with latch.
Call the physician for a prescription for formula.
Obtain consent from her to use donor breast milk.
Instruct her to burp after the baby eats 1/2 ounce.
The Correct Answer is A
A. Colostrum, the first form of breast milk, is produced in small amounts and is rich in nutrients and antibodies. Many new mothers are unaware of this and need reassurance.
B. Formula is not necessary unless medically indicated or the mother persists after being educated.
C. Donor breast milk is typically reserved for medically fragile infants.
D. Burping after feeding is important but does not address the client’s concern about milk supply.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Tachycardia: A compensatory response to cold stress as the infant tries to generate heat.
B. Shivering: Rare in newborns due to immature thermoregulation; not a common finding.
C. Hypoglycemia: Cold stress increases glucose consumption, risking hypoglycemia.
D. Lethargy: A late sign indicating worsening cold stress and potential hypothermia.
E. Hypertonia: Unrelated to cold stress, which more commonly causes hypotonia.
Correct Answer is D
Explanation
A. Hemolysis by maternal antibodies suggests hemolytic disease of the newborn (e.g., Rh incompatibility), which typically presents earlier and more severely.
B. Delayed meconium excretion may lead to increased bilirubin, but this is not the most common cause of jaundice at 3 days.
C. Pathological jaundice occurs within the first 24 hours or persists longer than a week.
D. Physiological jaundice is a common finding in newborns due to the natural breakdown of fetal red blood cells (RBCs) and the immature liver's inability to efficiently process bilirubin.
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