Chapter 22: Infant Feeding My Nursing Test Banks

Chapter 22: Infant Feeding

MULTIPLE CHOICE

1. The breastfeeding client should be taught a safe method to remove her breast from the babys mouth. Which suggestion by the nurse is most appropriate?

a.

Break the suction by inserting your finger into the corner of the infants mouth.

b.

A popping sound occurs when the breast is correctly removed from the infants mouth.

c.

Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed.

d.

Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.

ANS: A

Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple, making it sore. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.

PTS: 1 DIF: Cognitive Level: Application REF: 446

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

2. Which woman is most likely to continue breastfeeding beyond 6 months?

a.

A woman who avoids using bottles

b.

A woman who uses formula for every other feeding

c.

A woman who offers water or formula after breastfeeding

d.

A woman whose infant is satisfied for 4 hours after the feeding

ANS: A

Women who avoid using bottles and formula are more likely to continue breastfeeding.

Use of formula decreases breastfeeding time and decreases the production of prolactin and, ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The new breastfeeding mother needs to nurse often to stimulate milk production.

PTS: 1 DIF: Cognitive Level: Analysis REF: 453

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. In which condition is breastfeeding contraindicated?

a.

Triplet birth

b.

Flat or inverted nipples

c.

Human immunodeficiency virus infection

d.

Inactive, previously treated tuberculosis

ANS: C

Human immunodeficiency virus is a serious illness that can be transmitted to the infant via body fluids. Because the amount of milk being produced depends on the amount of suckling of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin to be treated during pregnancy but may begin after birth. Many methods help flat or inverted nipples to become more erect. Only active tuberculosis patients would be cautioned not to breastfeed.

PTS: 1 DIF: Cognitive Level: Understanding REF: 454

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment

4. Which type of formula should not be diluted before being administered to an infant?

a.

Powdered

b.

Concentrated

c.

Ready to use

d.

Modified cows milk

ANS: C

Ready to use formula can be poured directly from the can into the babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

PTS: 1 DIF: Cognitive Level: Understanding REF: 458

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day?

a.

50 to 75

b.

100 to 110

c.

120 to 140

d.

150 to 200

ANS: B

The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional needs each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are too much.

PTS: 1 DIF: Cognitive Level: Understanding REF: 436

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. How many milliliters per kilogram (mL/kg) of fluids does a newborn need daily for the first 3 to 5 days of life?

a.

20 to 30

b.

40 to 60

c.

60 to 100

d.

120 to 150

ANS: C

The newborn needs 60 to 100 mL/kg of fluids daily for the first 3 to 5 days of life. 20 to 30 mL/kg and 40 to 60 mL/kg are too small an amount for the newborn. 120 to 150 mL/kg is too large an amount for the newborn.

PTS: 1 DIF: Cognitive Level: Understanding REF: 436, 437

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

7. Which is the hormone necessary for milk production?

a.

Estrogen

b.

Prolactin

c.

Progesterone

d.

Lactogen

ANS: B

Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.

PTS: 1 DIF: Cognitive Level: Understanding REF: 441

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. Which recommendation should the nurse make to a client to initiate the milk ejection reflex?

a.

Wear a well-fitting firm bra.

b.

Drink plenty of fluids.

c.

Place the infant to the breast.

d.

Apply cool packs to the breast.

ANS: C

Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast but will not initiate the let-down reflex. Drinking plenty of fluids is necessary for adequate milk production but will not initiate the let-down reflex. Cool packs to the breast will decrease the let-down reflex.

PTS: 1 DIF: Cognitive Level: Application REF: 441

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

9. Which is the first step in assisting the breastfeeding mother?

a.

Assess the womans knowledge of breastfeeding.

b.

Provide instruction on the composition of breast milk.

c.

Discuss the hormonal changes that trigger the milk ejection reflex.

d.

Help her obtain a comfortable position and place the infant to the breast.

ANS: A

The nurse should first assess the womans knowledge and skill in breastfeeding to determine her teaching needs. Assessment should occur before instruction. Discussing the hormonal changes and helping her obtain a comfortable position may be part of the instructional plan, but assessment should occur first to determine what instruction is needed.

PTS: 1 DIF: Cognitive Level: Application REF: 443, 444

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

10. Which is an important consideration in positioning a newborn for breastfeeding?

a.

Placing the infant at nipple level facing the breast

b.

Keeping the infants head slightly lower than the body

c.

Using the forefinger and middle finger to support the breast

d.

Limiting the amount of areola the infant takes into the mouth

ANS: A

Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. Keeping the infants head slightly lower will pull the nipple down and cause trauma. The forefinger and middle finger can be used to support the breast, but this is not an important consideration in positioning the newborn. The infant should take in as much areola as possible to prevent trauma to the nipples.

PTS: 1 DIF: Cognitive Level: Analysis REF: 444

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

11. The client should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following?

a.

Unwrap and gently arouse the infant.

b.

Wait an hour and attempt to feed again.

c.

Try offering a bottle at the next feeding.

d.

Put the infant in the crib and try again later.

ANS: A

The infant who falls asleep during feeding may not have fed adequately and should be gently aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast milk production will decrease. The infant should be aroused and feeding continued.

PTS: 1 DIF: Cognitive Level: Application REF: 449

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

12. To prevent breast engorgement, what should the new breastfeeding mother be instructed to do?

a.

Feed her infant no more than every 4 hours.

b.

Limit her intake of fluids for the first few days.

c.

Apply cold packs to the breast prior to feeding.

d.

Breast-feed frequently and for adequate lengths of time.

ANS: D

Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, so waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before feedings.

PTS: 1 DIF: Cognitive Level: Application REF: 453

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

13. What is the difference between the aseptic and terminal methods of sterilization?

a.

The aseptic method requires a longer preparation time.

b.

The aseptic method does not require boiling of the bottles.

c.

The terminal method requires boiling water to be added to the formula.

d.

The terminal method sterilizes the prepared formula at the same time it sterilizes the equipment.

ANS: D

In the terminal sterilization method, the formula is prepared in the bottles, which are loosely capped, and then the bottles are placed in the sterilizer, where they are boiled for 25 minutes. The terminal method takes 25 minutes to boil; the aseptic method takes 5 minutes to boil. With the aseptic method, the bottles are boiled separate from the formula. With the terminal method, the formula is prepared, placed in bottles, and everything is boiled at one time.

PTS: 1 DIF: Cognitive Level: Understanding REF: 458

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment

14. How many ounces will an infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs?

a.

1

b.

1.5

c.

3.5

d.

5

ANS: C

The newborn requires approximately 12 to 24 oz of formula each day (6 feedings/24-hour period). 1 and 1.5 ounces are too small to meet calorie needs; 5 ounces with every feeding would be overfeeding the infant.

PTS: 1 DIF: Cognitive Level: Analysis REF: 459

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

15. A new mother is concerned because her 1-day-old newborn is taking only 1 oz at each feeding. What should the nurse explain?

a.

The infant is probably having difficulty adjusting to the formula.

b.

An infant does not require as much formula in the first few days of life.

c.

The infants stomach capacity is small at birth but will expand within a few days.

d.

The infant tires easily during the first few days but will gradually take more formula.

ANS: C

The infants stomach capacity at birth is 10 to 20 mL and increases to 30 to 90 mL by the end of the first week. There are other symptoms if there is a formula intolerance. The infants requirements are the same, but the stomach capacity needs to increase before taking in adequate amounts. The infants sleep patterns do change, but the infant should be awake enough to feed.

PTS: 1 DIF: Cognitive Level: Application REF: 446

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

16. As the nurse assists a new mother with breastfeeding, the mother asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The nurses best response is that it contains:

a.

more calcium.

b.

more calories.

c.

essential amino acids.

d.

important immunoglobulins.

ANS: D

Breast milk contains immunoglobulins that protect the newborn against infection. Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly. The calorie counts of formula and breast milk are about the same. All the essential amino acids are in formula and breast milk. The concentrations may differ.

PTS: 1 DIF: Cognitive Level: Application REF: 437

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

17. What should the nurse explain when responding to the question, Will I produce enough milk for my baby as she grows and needs more milk at each feeding?

a.

Early addition of baby food will meet the infants needs.

b.

The breast milk will gradually become richer to supply additional calories.

c.

As the infant requires more milk, feedings can be supplemented with cows milk.

d.

The mothers milk supply will increase as the infant demands more at each feeding.

ANS: D

The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Solids should not be added until about 4 to 6 months, when the infants immune system is more mature. This will decrease the chance of allergy formations. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production.

PTS: 1 DIF: Cognitive Level: Application REF: 441

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

18. Which should the nurse recommend to the postpartum client to prevent nipple trauma?

a.

Assess the nipples before each feeding.

b.

Limit the feeding time to less than 5 minutes.

c.

Wash the nipples daily with mild soap and water.

d.

Position the infant so the nipple is far back in the mouth.

ANS: D

If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for trauma is important, but it will not prevent sore nipples. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. Soap can be drying to the nipples and should be avoided during breastfeeding.

PTS: 1 DIF: Cognitive Level: Application REF: 458

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

19. A breastfeeding client who was discharged yesterday calls to ask about a tender hard area on her right breast. What should be the nurses first response?

a.

This is a normal response in breastfeeding mothers.

b.

Notify your doctor so he can start you on antibiotics.

c.

Stop breastfeeding because you probably have an infection.

d.

Try massaging the area and apply heat; it is probably a plugged duct.

ANS: D

A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation.

PTS: 1 DIF: Cognitive Level: Application REF: 451

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

20. Which is an important consideration about the storage of breast milk?

a.

Can be thawed and refrozen

b.

Can be frozen for up to 2 months

c.

Should be stored only in glass bottles

d.

Can be kept refrigerated for 48 hours

ANS: D

If used within 48 hours after being refrigerated, breast milk will maintain its full nutritional value. It should not be refrozen. Frozen milk should be kept for 1 month only. Antibodies in the milk will adhere to glass bottles. Only rigid polypropylene plastic containers should be used.

PTS: 1 DIF: Cognitive Level: Understanding REF: 458

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment

21. What is the most serious consequence of propping an infants bottle?

a.

Colic

b.

Aspiration

c.

Dental caries

d.

Ear infections

ANS: B

Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. Colic can occur but is not the most serious consequence. Dental caries becomes a problem when milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs. However, this is not the most serious consequence.

PTS: 1 DIF: Cognitive Level: Understanding REF: 459

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

22. A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurses best response?

a.

Formula may turn sour after it is opened.

b.

Bacteria can grow rapidly in warm milk.

c.

Formula loses some nutritional value once it is opened.

d.

This makes it easier to keep track of how much the baby is taking.

ANS: B

Formula should not be saved from one feeding to the next because of the danger of rapid growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This will cause problems in a newborn with an immature immune system. The loss of some nutritional value after the formula is opened is not the reason for using fresh bottles with each feeding. The danger of bacterial growth is the main concern.

PTS: 1 DIF: Cognitive Level: Application REF: 459

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

23. A new mother asks whether she should feed her newborn colostrum because it is not real milk. The nurses best answer includes which information?

a.

Colostrum is unnecessary for newborns.

b.

Colostrum is high in antibodies, protein, vitamins, and minerals.

c.

Colostrum is lower in calories than milk and should be supplemented by formula.

d.

Giving colostrum is important in helping the mother learn how to breast-feed before she goes home.

ANS: B

Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Colostrum provides immunity and enzymes necessary to clean the gastrointestinal system, among other things. Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge, but the importance of the colostrum to the infant is top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 437

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

24. A newborn infant weighs 7 pounds, 2 ounces, on the fifth day of life. How much water should be given to the newborn based on required fluid needs?

a.

Fluid replacement should be based on weight and calculated in the range of 60 to 100 mL/kg.

b.

Offer additional water to tolerance in between infant feedings to maintain hydration.

c.

Give 12 ounces of fluid per feeding.

d.

No water is needed because formula and breast milk are adequate to maintain hydration.

ANS: A

There is an expected weight loss of up to 10% postdelivery, so fluid replacement should be calculated to improve health outcomes and maintain adequate hydration.12 ounces of fluid per feeding is excessive and may cause overdistention. Offering water between feedings to tolerance may not provide enough fluid replacement. Newborn infants require additional water to supplement feedings and support hydration.

PTS: 1 DIF: Cognitive Level: Analysis REF: 437

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

25. A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The best nursing response would be to:

a.

tell the client to wear a bra at all times to provide more support to breast tissue.

b.

have the client put the infant to her breast more frequently.

c.

place ice packs on breast tissue after infant feeding.

d.

explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.

ANS: B

The client may be experiencing signs of engorgement. Intervention methods such as placing the infant to feed more frequently may help prevent physical complaints of tenderness to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but can provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement issues. Warm water compresses are more likely to provide comfort. Engorgement is not a normal finding but is a common presentation in nursing mothers. These symptoms will not dissipate with continuation of breastfeeding.

PTS: 1 DIF: Cognitive Level: Application REF: 442, 451

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

26. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, the nurse would designate a score of:

a.

10 and document findings in the chart.

b.

6 and further teach and assist the mother in feeding activities.

c.

5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.

d.

8 and no further assistance is needed for feeding.

ANS: B

The LATCH assessment tool is used to identify whether mothers need additional instruction in the area of breastfeeding. The LATCH categories are latch, audible communication/swallowing, type of nipple, comfort of breasts, and holding position of infant. The assessment data reveal a score of 6 (0 + 2 + 1 + 2 + 1) so the mother needs additional assistance during breastfeeding at this time.

PTS: 1 DIF: Cognitive Level: Analysis REF: 443

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

27. A mother conveys concern over the fact that she is not sure if her newborn child is getting enough nutrients from breastfeeding. This is the babys first clinic visit after birth. What information can you provide that will help alleviate her fears about nutrient status for her newborn?

a.

Monitor the infants output; as long as at least six or more diapers are changed in a 24-hour period, that should be sufficient.

b.

Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy.

c.

Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition.

d.

Provide nutrition information in the form of pamphlets for the mother to take home with her so that she uses them as a point of reference.

ANS: A

The presence of wet diapers confirms that the infant is receiving enough milk. Recording weight and seeing an increase in weight is also an objective finding that can be used to note nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although breast milk is potentially the perfect food for the newborn, not everyones breast milk has nutrient quality, so recording of weight gain and output measurements (wet diapers and stool production) confirm nutritional status. Providing the mother with educational pamphlets may be advisable but does not address the immediate problem.

PTS: 1 DIF: Cognitive Level: Application REF: 448

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

28. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurses best response?

a.

Are you concerned about your ability to adequately nurse your baby?

b.

Do you eat a well-balanced diet, high in protein and carbohydrates?

c.

Breast milk is low in vitamin D and supplementation with 400 IU is recommended.

d.

Your breast milk has all the vitamins and will adequately meet your babys needs.

ANS: C

Generally, nutrients provided in breast milk are present in amounts and proportions needed by the infant. However, recent studies have shown that the vitamin D content of breast milk is low, and daily supplementation with 400 IU of vitamin D is recommended within the first few days of life. Breastfeeding infants who are not exposed to the sun and those with dark skin are particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart of vitamin Dfortified milk per day should also be supplemented. Although the fatty acid content of breast milk is influenced by the mothers diet, malnourished mothers milk has about the same proportions of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk are affected by the mothers intake and stores. It is important for breastfeeding women to eat a well-balanced diet to maintain their own health and energy levels.

PTS: 1 DIF: Cognitive Level: Application REF: 437

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

29. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding?

a.

I should encourage my baby to consume the entire amount of formula prepared for each feeding.

b.

I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.

c.

I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby.

d.

I will generally feed my baby every 3 to 4 hours or more as signs of hunger are displayed.

ANS: A

Infants will stop suckling when they are full. Encouraging them to overeat may lead to problems with regurgitation and possible aspiration. The mother can prepare a single bottle or a 24-hour supply if adequate refrigeration is available. Show the parents how to position the infant in a semiupright position, such as the cradle hold. This allows them to hold the infant close in a faceto-face position. The bottle is held with the nipple kept full of formula to prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but avoid rigid scheduling and take cues from the infant.

PTS: 1 DIF: Cognitive Level: Analysis REF: 458

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

30. A client who is receiving a pitocin (Oxytocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority?

a.

Increase the rate of pitocin infusion to help spread out the contraction pattern.

b.

Place oxygen on the client at 8 to 10 L/min via face mask and turn the client to her left side.

c.

Stop the pitocin infusion.

d.

Call the physician to obtain an order for the initiation of magnesium sulfate.

ANS: C

The client is exhibiting uterine tachysystole (uterine tetany). The priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be contacted for additional orders.

PTS: 1 DIF: Cognitive Level: Analysis REF: 441

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

31. The nurse is teaching a postpartum client different holds for breastfeeding. Which of the following figures depicts the football hold frequently used for clients who have had a cesarean birth?

a.

b.

c.

d.

ANS: C

For the football or clutch hold, the mother supports the infants head and neck in her hand, with the infants body resting on pillows next to her hip. This method allows the mother to see the position of the infants mouth on the breast, helps her control the infants head, and is especially helpful for mothers with heavy breasts. This hold also avoids pressure against an abdominal incision. For the cradle hold, the mother positions the infants head at or near the antecubital space and level with her nipple, with her arm supporting the infants body. Her other hand is free to hold the breast. The cross-cradle or modified cradle hold is helpful for infants who are preterm or have a fractured clavicle. The mother holds the infants head with the hand opposite the side on which the infant will feed and supports the infants body across her lap with her arm. The other hand holds the breast. The side-lying position avoids pressure on the episiotomy or abdominal incision and allows the mother to rest while feeding.

PTS: 1 DIF: Cognitive Level: Analysis REF: 445

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

32. Late in pregnancy, the clients breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Which of the following nipple conditions make it necessary to intervene before birth. (Select all that apply.)

a.

Flat nipples

b.

Cracked nipples

c.

Everted nipples

d.

Inverted nipples

e.

Nipples that contract when compressed

ANS: A, D, E

Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infants mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra, with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells has been debated. A breast pump can be used to draw the nipples out before feedings after birth. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latching on. The infant should be repositioned during feeding. The application of colostrum and breast milk after feedings will aid in healing.

PTS: 1 DIF: Cognitive Level: Application REF: 451

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

33. Which interventions may relieve symptoms of colic in the infant? (Select all that apply.)

a.

Increased stimulation of infant to provide distraction

b.

Burping infant frequently during feedings

c.

Feeding infant placed in an upright position

d.

Providing chamomile tea to infant

e.

Feeding infant on an on demand schedule

ANS: B, C, D

The presence of colic is a self-limiting temporary condition seen in infants during the first few months of life. Although there are many theories about its cause, none has been determined to show direct causation. Providing a quiet environment and a consistent feeding schedule, positioning the infant in an upright position during feeding, burping the infant frequently, and using supplements or medications that have antispasmodic properties may be recommended. Chamomile tea is reported to have antispasmodic effects. Feeding the infant on an on demand schedule may exacerbate the condition as a result of overfeeding.

PTS: 1 DIF: Cognitive Level: Application REF: 458

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

34. For which infant should the nurse anticipate the use of soy formula? (Select all that apply.)

a.

Preterm infant

b.

Infant with galactosemia

c.

Infant with phenylketonuria

d.

Infant with lactase deficiency

e.

Infant with a malabsorption disorder

ANS: B, D, E

Soy formula may be given to infants with galactosemia or lactase deficiency or those whose families are vegetarians. Soy milk is derived from the protein of soybeans and supplemented with amino acids. The formulas are also used for infants with malabsorption disorders. The preterm infant may require a more concentrated formula, with more calories in less liquid. Modifications of other nutrients are also made. Human milk fortifiers can be added to breast milk to adapt it for preterm infants. Low-phenylalanine formulas are needed for infants with phenylketonuria, a deficiency in the enzyme to digest phenylalanine found in standard formulas.

PTS: 1 DIF: Cognitive Level: Analysis REF: 438

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

35. A new mother asks the nurse, How will I know early signs of hunger in my baby? The nurses best response is which of the following? (Select all that apply.)

a.

Crying

b.

Rooting

c.

Lip smacking

d.

Decrease in activity

e.

Sucking on the hands

ANS: B, C, E

Early signs of hunger in a baby are rooting, lip smacking, and sucking on the hands. Crying is a late sign, and the babys activity will increase, not decrease.

PTS: 1 DIF: Cognitive Level: Application REF: 443

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

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