The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a special feeding device that has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. Which instructions should the nurse provide the mother about feedings?

Squeeze the nipple base to introduce milk into the mouth.

Position the baby in the left lateral position after feeding.

Alternate milk with water during the feeding.

Hold the newborn in an upright position.

Answer and Explanation

The Correct Answer is D

A. Squeeze the nipple base to introduce milk into the mouth: This may increase the risk of aspiration if milk flows too rapidly, especially in infants with cleft lips who have difficulty forming a tight seal and managing suck-swallow coordination effectively.

B. Position the baby in the left lateral position after feeding: Although side-lying may aid digestion in some cases, it’s not the priority after feeding a newborn with cleft lip. Upright positioning is safer and helps reduce aspiration risk.

C. Alternate milk with water during the feeding: Offering water during feedings is not recommended for newborns, as it can displace nutritional intake and may disrupt electrolyte balance. It also offers no benefit for cleft lip management.

D. Hold the newborn in an upright position: This reduces the risk of aspiration by improving control of milk flow and promoting effective swallowing. It is the safest and most effective position for feeding an infant with cleft lip.

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Correct Answer is A

Explanation

A. Provide a bedside commode for toileting: This intervention helps reduce the cardiac workload by minimizing the effort needed for the client to walk to the bathroom. It allows the client to conserve energy and reduce the strain on the heart.

B. Assist with ambulation in the hallway: While mobility is important, ambulating in the hallway can increase the heart’s workload, especially in a client with heart failure and pneumonia. It's best to minimize unnecessary physical exertion to prevent exacerbations.

C. Teach to sleep in a side-lying position: While side-lying can sometimes help with breathing, this position does not directly reduce the cardiac workload. The priority is ensuring the client has adequate rest and minimizing physical strain.

D. Encourage active range of motion exercises: While range of motion exercises are important for preventing complications like muscle atrophy, they may increase the cardiac workload. For a client with pneumonia and heart failure, the priority is to reduce exertion and conserve energy.

A. Blood alcohol level of 0.09% (19.5 mmol/L). B. Weight loss of 10 lb (4.5 kg) in past month. C. Six hours of sleep in the past three days. D. Serum lithium level of 1.6 mEq/L (1.6 mmol/L).

Correct Answer is D

Explanation

A. Blood alcohol level of 0.09% (19.5 mmol/L): This alcohol level indicates mild intoxication. It can cause slurred speech and gait changes, but the effects are usually transient and less concerning than drug toxicity. It should be monitored, but is not as urgent as lithium toxicity.

B. Weight loss of 10 lb (4.5 kg) in past month: This degree of weight loss may suggest poor nutritional intake or a depressive episode, but it is not immediately life-threatening. It requires follow-up but does not explain the acute neurological signs the client is exhibiting.

C. Six hours of sleep in the past three days: Severe sleep deprivation can exacerbate mood instability in bipolar disorder, but it does not account for slurred speech or gait disturbances. This concern is significant for mental health management but not the priority in this situation.

D. Serum lithium level of 1.6 mEq/L (1.6 mmol/L): This is above the therapeutic range and suggests lithium toxicity, which can cause neurological signs such as slurred speech and ataxia. Immediate reporting is crucial to prevent progression to more severe toxicity, including seizures or coma.

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Naxlex Comprehensive Predictor Exams

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?

Exhibits The nurse is preparing the client's plan of care. A major component of the clients at home care is pain management. Select the 3 most important interventions the nurse can educate the client with rheumatoid arthritis (RA) about to help with pain management.

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?