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 A
Explanation
Choice A rationale
Meconium is an infant's first stool, composed of amniotic fluid, lanugo, bile, and intestinal epithelial cells. Most infants pass meconium within the first 24 hours of life. Failure to pass meconium within 24 hours can indicate a bowel obstruction, such as Hirschsprung's disease or meconium ileus, necessitating immediate medical evaluation.
Choice B rationale
The amount of formula consumed by a 24-hour-old infant can vary. While adequate feeding is important, not finishing a 3 oz bottle at this early stage may not be as immediately concerning as the absence of meconium, as gastric capacity is still developing.
Choice C rationale
While three wet diapers indicate adequate hydration and renal function, which is positive, the absence of meconium stool is a more critical physiological assessment requiring urgent attention due to potential underlying pathology.
Choice D rationale
The use of a bulb syringe suggests the infant may have some respiratory secretions, which can be normal variations. This finding, while noted, does not carry the same level of immediate concern as the absence of meconium passage in a 24-hour-old.
Correct Answer is D
Explanation
Choice A rationale
Collecting a urine specimen for electrolytes and protein would provide data related to renal function and fluid balance, but it does not directly address the client's current subjective symptoms of restlessness and apprehension. These symptoms are more indicative of potential hypoxemia or a psychological response to stress, which requires a more immediate and direct assessment and intervention focused on maternal-fetal well-being rather than baseline lab work. Normal urine specific gravity is 1.005-1.030, and protein should be negative.
Choice B rationale
Moving the client into a dorsal recumbent position can actually compress the inferior vena cava, leading to supine hypotensive syndrome, which further compromises placental perfusion and exacerbates fetal distress. This position is contraindicated in laboring clients, particularly when signs of potential distress are present. The ideal position for laboring clients is typically left lateral, which optimizes uterine perfusion and oxygenation.
Choice C rationale
Encouraging the client to push with the next contraction is inappropriate given the client's symptoms of restlessness and apprehension, especially at 42 weeks gestation with chorioamnionitis. These symptoms could indicate evolving fetal distress or a change in maternal status requiring further assessment, not active pushing. Pushing without complete cervical dilation can lead to cervical edema or trauma.
Choice D rationale
Providing information about the baby's status can alleviate the client's anxiety and apprehension by addressing her immediate concerns about the well-being of her fetus. Restlessness and apprehension in a laboring client, particularly with a diagnosis of chorioamnionitis, can be a symptom of hypoxemia or other complications. Open communication and reassurance are crucial in managing maternal stress and promoting a sense of control.
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