While caring for a 3-month-old infant, the practical nurse (PN) observes the mother propping the bottle on a pillow to feed the child.
Which should the PN implement?
Encourage the mother not to prop the bottle.
Share the observation with the charge nurse.
Ask the mother if she is too tired to feed her baby.
Observe the infant's behavior during the feeding.
The Correct Answer is A
Choice A rationale
Propping a bottle can lead to several adverse outcomes for an infant. It increases the risk of aspiration, as the infant may not be able to control the milk flow adequately. It can also contribute to otitis media due to milk pooling in the eustachian tubes and is associated with dental caries, particularly bottle mouth syndrome, and impaired bonding.
Choice B rationale
Sharing the observation with the charge nurse without first addressing the issue directly with the mother is not the most immediate or appropriate action. The PN should first attempt to educate and guide the mother, as this is within the scope of practice for direct client care and education.
Choice C rationale
Asking the mother if she is too tired is speculative and may be perceived as judgmental, potentially creating a barrier to effective communication and education. The PN's role is to provide health education and guidance regarding safe infant feeding practices, focusing on the behavior rather than the mother's perceived fatigue.
Choice D rationale
While observing the infant's behavior during feeding is important for a comprehensive assessment, the immediate and most critical action is to intervene with the unsafe practice of bottle propping. Observing further without addressing the identified risk delays necessary education and intervention to ensure infant safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A soft, spongy fundus, often described as boggy, indicates uterine atony. This condition means the uterine muscles are not contracting effectively, which is abnormal postpartum and significantly increases the risk of postpartum hemorrhage due to inadequate compression of uterine blood vessels.
Choice B rationale
Unilateral lower leg pain, especially accompanied by warmth, redness, or swelling, is an abnormal finding and can be indicative of a deep vein thrombosis (DVT). Postpartum women are at an increased risk for DVT due to hypercoagulability and venous stasis, making this a critical assessment requiring immediate attention.
Choice C rationale
Saturating two perineal pads per hour is an excessive amount of lochia and suggests postpartum hemorrhage. Normal lochia flow should not saturate more than one pad per hour in the immediate postpartum period, indicating that the uterus is not contracting adequately to control bleeding.
Choice D rationale
A heart rate of 56 beats/minute, also known as puerperal bradycardia, is considered a normal physiological finding for a primigravida client 12 hours postpartum. This transient bradycardia often occurs due to the increased stroke volume and cardiac output that result from the significant decrease in uterine blood flow after delivery.
Correct Answer is C
Explanation
Choice A rationale
While wearing a supportive bra can manage symptoms like leaking, it does not address the underlying physiological changes or provide reassurance about their normalcy during pregnancy. The primary concern is to alleviate anxiety and provide accurate information, not just symptom management. Breast changes are common, and this choice does not prioritize assessment or explanation.
Choice B rationale
Rescheduling the appointment prematurely might cause unnecessary anxiety for the client if the symptoms are indeed normal. It disrupts the established prenatal care schedule without sufficient clinical indication. Unless acute distress or clear signs of pathology are present, waiting for the scheduled visit is generally appropriate.
Choice C rationale
During the third trimester, breast tissue undergoes significant hormonal changes in preparation for lactation, leading to increased vascularity, glandular growth, and sometimes the leakage of colostrum, a yellowish fluid. These are normal physiological adaptations, and reassuring the client while noting it for the upcoming visit provides appropriate, evidence-based care.
Choice D rationale
While darkened areolae are another common physiological change during pregnancy due to increased melanocyte-stimulating hormone, asking about it does not directly address the client's current concerns about "lumpy places" or fluid leakage. It's a related but separate observation, and the initial focus should be on explaining the normal changes the client is reporting.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.