Pediatric Primary Care Practice Guidelines For Nurses By Beth Richardson – Test Bank
Chapter 4 Making Newborn Rounds
- What is a function of brown adipose tissue (BAT) in newborns?
- Generates heat for distribution to other parts of body
- Provides ready source of calories in the newborn period
- Protects newborns from injury during the birth process
- Insulates the body against lowered environmental temperature
Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial
cytochromes and a greater capacity for heat production through intensified metabolic activity
than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the
body by the blood. It is effective only in heat production. Brown fat is located in superficial areas
such as between the scapulae, around the neck, in the axillae, and behind the sternum. These
areas should not protect the newborn from injury during the birth process. The newborn has a
thin layer of subcutaneous fat, which does not provide for conservation of heat.
- Which characteristic is representative of a full-term newborns gastrointestinal tract?
- Transit time is diminished.
- Peristaltic waves are relatively slow.
- Pancreatic amylase is overproduced.
- Stomach capacity is very limited.
Newborns require frequent small feedings because their stomach capacity is very limited. A
newborns colon has a relatively small volume and resulting increased bowel movements.
Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats.
- Which term is used to describe a newborns first stool?
- Milk stool
Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal
cells, and possibly blood. It is a newborns first stool. Milia involves distended sweat glands that
appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The
appearance varies depending on whether the newborn is breast or formula fed. Transitional stools
usually appear by the third day after the beginning of feeding. They are usually greenish brown
to yellowish brown, thin, and less sticky than meconium.
- In term newborns, the first meconium stool should occur no later than within how many hours
The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days
in very lowbirth-weight newborns.
- Which is true regarding an infants kidney function?
- Conservation of fluid and electrolytes occurs.
- Urine has color and odor similar to the urine of adults.
- The ability to concentrate urine is less than that of adults.
- Normally, urination does not occur until 24 hours after delivery.
At birth, all structural components are present in the renal system, but there is a functional
deficiency in the kidneys ability to concentrate urine and to cope with conditions of fluid and
electrolyte stress such as dehydration or a concentrated solute load. Infants urine is colorless and
odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the
bladder is stretched to 15 ml, resulting in about 20 voidings per day.
- The Apgar score of an infant 5 minutes after birth is 8. Which is the nurses best interpretation
- Resuscitation is likely to be needed.
- Adjustment to extrauterine life is adequate.
- Additional scoring in 5 more minutes is needed.
- Maternal sedation or analgesia contributed to the low score.
The Apgar reflects an infants status in five areas: heart rate, respiratory effort, muscle tone,
reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to
extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 7 indicate moderate
difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of
distress; the newborn does not have a low score. The Apgar score is not used to determine the
infants need for resuscitation at birth.
- Which statement best represents the first stage or the first period of reactivity in the infant?
- Begins when the newborn awakes from a deep sleep
- Is an excellent time to acquaint the parents with the newborn
- Ends when the amounts of respiratory mucus have decreased
- Provides time for the mother to recover from the childbirth process
During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist
greedily, and appears interested in the environment. The infants eyes are usually wide open,
suggesting that this is an excellent opportunity for mother, father, and infant to see each other.
The second period of reactivity begins when the infant awakes from a deep sleep and ends when
the amounts of respiratory mucus have decreased. The mother should sleep and recover during
the second stage, when the infant is sleeping.
- Which statement reflects accurate information about patterns of sleep and wakefulness in the
- States of sleep are independent of environmental stimuli.
- The quiet alert stage is the best stage for newborn stimulation.
- Cycles of sleep states are uniform in newborns of the same age.
- Muscle twitches and irregular breathing are common during deep sleep.
During the quiet alert stage, the newborns eyes are wide open and bright. The newborn responds
to the environment by active body movement and staring at close-range objects. Newborns
ability to control their own cycles depend on their neurobehavioral development. Each newborn
has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.
- The nurse observes that a new mother avoids making eye contact with her infant. What should
the nurse do?
- Ask the mother why she wont look at the infant.
- Examine the infants eyes for the ability to focus.
- Assess the mother for other attachment behaviors.
- Recognize this as a common reaction in new mothers.
Attachment behaviors are thought to indicate the formation of emotional bonds between the
newborn and mother. A mothers failure to make eye contact with her infant may indicate
difficulties with the formation of emotional bonds. The nurse should perform a more thorough
assessment. Asking the mother why she will not look at the infant is a confrontational response
that might put the mother in a defensive position. Infants do not have binocularity and cannot
focus. Avoiding eye contact is an uncommon reaction in new mothers.
- Which should the nurse use when assessing the physical maturity of a newborn?
- Apgar score
- Posture at rest
- Chest circumference
With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can
be used for determination of gestational age. Length and chest circumference reflect the
newborns size and weight, which vary according to race and gender. Birth weight alone is a poor
indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborns
adjustment to extrauterine life.
- What is the grayish white, cheeselike substance that covers the newborns skin?
- Amniotic fluid
- Vernix caseosa
The vernix caseosa is the grayish white, cheeselike substance that covers a newborns skin.
- What is most descriptive of the shape of the anterior fontanel in a newborn?
The anterior fontanel is diamond shaped and measures from barely palpable to 4 to 5 cm. The
shape of the posterior fontanel is a triangle. Neither of the fontanels is a circle or a square.
- Which term describes irregular areas of deep blue pigmentation seen predominantly in
infants of African, Asian, Native American, or Hispanic descent?
- Mongolian spots
- Erythema toxicum
- Harlequin color change
Mongolian spots are irregular areas of deep blue pigmentation, which are common variations
found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is
cyanosis of the hands and feet; this is a usual finding in infants. Erythema toxicum is a pink
papular rash with vesicles that may appear in 24 to 48 hours and resolve after several days.
Harlequin color changes are clearly outlined areas of color change. As the infant lies on a side,
the lower half of the body becomes pink, and the upper half is pale.
- The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
- 60 to 80 beats/min
- 80 to 100 beats/min
- 120 to 140 beats/min
- 160 to 180 beats/min
The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between
120 and 140 beats/min. Sixty to 100 beats/min is too slow for a newborn, and 160 to 180
beats/min is too fast for a newborn.
- Which finding in the newborn is considered abnormal?
- Profuse drooling
- Dark green or black stools
- Slight vaginal reddish discharge
Profuse drooling and salivation are potential signs of a major abnormality. Newborns with
esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling.
Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns.
Meconium, the first stool of newborns, is dark green or black. A pseudomenstruation may be
present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.
- When doing the first assessment of a male newborn, the nurse notes that the scrotum is large,
edematous, and pendulous. What should this be interpreted as?
- A hydrocele
- An inguinal hernia
- A normal finding
- An absence of testes
A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a
breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral,
which usually resolves within a few months. An inguinal hernia may or may not be present at
birth. It is more easily detected when the child is crying. The presence or absence of testes
should be determined on palpation of the scrotum and inguinal canal. Absence of testes may be
an indication of ambiguous genitalia.
- Why are rectal temperatures not recommended in newborns?
- They are inaccurate.
- They do not reflect core body temperature.
- They can cause perforation of rectal mucosa.
- They take too long to obtain an accurate reading.
Rectal temperatures are avoided in newborns. If done incorrectly, the insertion of a thermometer
into the rectum can cause perforation of the mucosa. The time it takes to determine body
temperature is related to the equipment used, not only the route.
- Which is the name of the suture separating the parietal bones at the top of a newborns head?
The sagittal suture separates the parietal bones at the top of the newborns head. The frontal
suture separates the frontal bones. The coronal suture is said to crown the head. The lambdoid
suture is at the margin of the parietal and occipital.
- The nurse observes flaring of nares in a newborn. What should this be interpreted as?
- Nasal occlusion
- Sign of respiratory distress
- Snuffles of congenital syphilis
- Appropriate newborn breathing
Nasal flaring is an indication of respiratory distress. A nasal occlusion should prevent the child
from breathing through the nose. Because newborns are obligatory nose breathers, this should
require immediate referral. Snuffles are indicated by a thick, bloody nasal discharge without
sneezing. Sneezing and thin, white mucus drainage are common in newborns and are not related
to nasal flaring.
- The nurse is assessing the reflexes of a newborn. Stroking the outer sole of the foot assesses
- Dance or step
This is a description of the Babinski reflex. Stroking the outer sole of the foot upward from the
heel across the ball of the foot causes the big toes to dorsiflex and the other toes to hyperextend.
This reflex persists until approximately age 1 year or when the newborn begins to walk. The
grasp reflex is elicited by touching the palms or soles at the base of the digits. The digits will flex
or grasp. The Perez reflex involves stroking the newborns back when prone; the child flexes the
extremities, elevating the head and pelvis. This disappears at ages 4 to 6 months. When the
newborn is held so that the sole of the foot touches a hard surface, there is a reciprocal flexion
and extension of the leg, simulating walking. This reflex disappears by ages 3 to 4 weeks.
- Which is most important in the immediate care of the newborn?
- Maintain a patent airway.
- Administer prophylactic eye care.
- Maintain a stable body temperature.
- Establish identification of the mother and baby.
Maintaining a patent airway is the primary objective in the care of the newborn. First, the
pharynx is cleared with a bulb syringe followed by the nasal passages. Administering
prophylactic eye care and establishing identification of the mother and baby are important
functions, but physiologic stability is the first priority in the immediate care of the newborn.
Conserving the newborns body heat and maintaining a stable body temperature are important,
but a patent airway must be established first.
- What should nursing interventions to maintain a patent airway in a newborn include?
- Positioning the newborn supine after feedings.
- Wrapping the newborn as snugly as possible.
- Placing the newborn to sleep in the prone (on abdomen) position.
- Using a bulb syringe to suction as needed, suctioning the nose first and then the pharynx.
Positioning the newborn supine after feedings is recommended by the American Academy of
Pediatrics to prevent sudden newborn death syndrome. The child can be wrapped snugly but
should be placed on the side or back. Placing a newborn to sleep in the prone (on abdomen)
position is not advised because of the possible link between sleeping in the prone position and
sudden newborn death syndrome. A bulb syringe should be kept by the bedside if necessary, but
the pharynx should be suctioned before the nose.
- The nurse quickly dries the newborn after delivery. This is to conserve the newborns body
heat by preventing heat loss through which method?
Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the
amniotic fluid. Radiation is the loss of heat to a cooler solid object. The cold air from either the
window or the air conditioner will cool the walls of the incubator and subsequently the body of
the newborn. Conduction involves the loss of heat from the body because of direct contact of the
skin with a cooler object. Convection is similar to conduction but is the loss of heat aided by air
- An infant is being discharged at 48 hours of age. The parents ask how the infant should be
bathed this first week home. Which is the best recommendation by the nurse?
- Bathe the infant daily with mild soap.
- Bathe the infant daily with an alkaline soap.
- Bathe the infant two or three times this week with mild soap.
- Bathe the infant two or three times this week with plain water.
A newborn infants skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect.
The parents should be taught to use only plain warm water for the bath and to bathe the infant no
more than two or three times the first 2 weeks. Soaps are alkaline. They will alter the acid mantle
of the infants skin, providing a medium for bacterial growth.
- The stump of the umbilical cord usually drops off in how many days?
- 3 to 6
- 10 to 14
- 16 to 21
- 24 to 28
The average umbilical cord separates in 10 to 14 days. Three to 6 days is too soon, and 16 to 28
days is too late.
- The parents of an infant plan to have him circumcised. They ask the nurse about pain
associated with this procedure. The nurses response should be based on which?
- That infants experience pain with circumcision
- That infants are too young for anesthesia or analgesia
- That infants do not experience pain with circumcision
- That infants quickly forget about the pain of circumcision
Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended
that procedural analgesia be provided when circumcision is performed. The pain infants
experience with surgical procedures can be alleviated with analgesia. Infants who undergo
circumcision without anesthetic agents react more intensely to immunization injections at 4 to 6
months of age compared with infants who had an anesthetic.
- The nurse is teaching a class on breastfeeding to expectant parents. Which is a
contraindication for breastfeeding?
- Twin births
- Inverted nipples
- Maternal cancer therapy
Mothers receiving chemotherapy with antimetabolites and certain antineoplastic drugs should not
breastfeed. The drugs are passed to the newborn through the breast milk. Mastitis, twin births,
and inverted nipples are not contraindications.
- Successful breastfeeding is most dependent on which?
- Birth weight of newborn
- Size of mothers breasts
- Mothers desire to breastfeed
- Familys socioeconomic level
The factors that contribute to successful breastfeeding are the mothers desire to breastfeed,
satisfaction with breastfeeding, and available support systems. Very lowbirth-weight infants may
be unable to breastfeed. The mother can express milk, and it can be used for the infant. The size
of mothers breasts does not affect the success of breastfeeding. The familys socioeconomic level
may affect the mothers need to return to work and available support systems, but with support,
the mother can be successful.
- A mother who breastfeeds her 6-week-old infant every 4 hours tells the nurse that he seems
hungry all the time. The nurse should recommend which?
- Newborn cereal
- Supplemental formula
- More frequent feedings
- No change in feedings
Infants who are breastfed tend to be hungry every 2 to 3 hours. They should be fed frequently.
Six weeks is too early to introduce newborn cereal. Supplemental formula is not indicated.
Giving additional formula or water to a breastfed infant may satiate the infant and create
problems with breastfeeding. The infant requires additional feedings. Four hours is too long
between feedings for a breastfed infant.
- What should a nursing intervention to promote parentinfant attachment include?
- Encouraging parents to hold the infant frequently unless the infant is fussy
- Explaining individual differences among infants to the parents
- Delaying parentinfant interactions until the second period of reactivity
- Alleviating stress for parents by decreasing their participation in the infants care
Nurses can positively influence the attachment of parent and infant by recognizing and
explaining individual differences to the parents. The nurse should emphasize the normalcy of
these variations and demonstrate the uniqueness of each infant. The parents should be
encouraged to hold the infant when he or she is fussy and learn how best to soothe their infant.
The nurse should facilitate parentinfant interaction during the first period of reactivity.
Decreasing the parents participation in care interferes with parentinfant attachment.
- A new mother wants to be discharged with her infant as soon as possible. Before discharge,
what should the nurse be certain of?
- The infant has voided at least once.
- The infant does not spit up after feeding.
- Jaundice, if present, appeared before 24 hours.
- A follow-up appointment with the practitioner is made within 48 hours.
The American Academy of Pediatrics recommends that newborns discharged early receive
follow-up care within 48 hours in either a primary practitioners office or the home. The child
should void every 4 to 6 hours. Spitting up small amounts after feeding is normal in newborns; it
should not delay discharge. Jaundice within the first 24 hours of life must be evaluated.
- The nurse is teaching new parents about the benefits of breastfeeding their infant. Which
statement by the parent should indicate a correct understanding of the teaching?
- I should breastfeed my baby so that she will grow at a faster rate than a bottle-fed newborn.
- One of the advantages of breastfeeding is that the baby will have fewer stools per day.
- I should breastfeed my baby because breastfed babies adapt more easily to a regular schedule of feedings.
Some of the advantages of breastfeeding are that breast milk is economical and readily available for my
Some advantages of breastfeeding a newborn are that breast milk is more economical, is readily
available, and is sanitary. Breastfed newborns usually grow at a satisfactory, slower rate than
bottle-fed newborns, which research indicates aids in decreased obesity in children. Breastfed
babies have an increased number of stools throughout a 24-hour period, and neither breastfed nor
bottle-fed newborns should be placed on a regular schedule; they should be fed on demand.
- The nurse is caring for a patient who has chosen to breastfeed her infant. Which statement
should the nurse include when teaching the mother about breastfeeding problems that may
If you experience painful nipples, cleanse your nipples with soap two times per day and keep your nipples
covered as much as possible.
- If you experience plugged ducts, continue to breastfeed every 2 to 3 hours and alternate feeding positions.
If mastitis occurs, discontinue breastfeeding while taking prescribed antibiotics and apply warm
- If engorgement occurs, use cold compresses before a feeding and wear a well-fitting bra at night.
If a woman experiences plugged ducts, the best interventions are to continue breastfeeding every
2 to 3 hours and alternate feeding positions while pointing the infants chin toward the obstructed
area. Other interventions include massaging breasts and applying warm compresses before
feeding or pumping. If painful nipples occur, the woman should avoid soaps, oils, and lotions
and air the nipples as much as possible. If mastitis occurs, the woman should continue
breastfeeding to keep the breast well drained. If engorgement occurs, the woman should use a
warm compress before feedings and wear a well-fitting bra 24 hours a day.
- The nurse is completing a physical and gestational age assessment on an infant who is 12
hours old. Which components are included in the gestational age assessment? (Select all that
- Arm recoil
- Popliteal angle
- Motor performance
- Primitive reflexes
- Square window
- Scarf sign
ANS: A, B, E, F
The components of the typical gestational age assessment include posture, square window, arm
recoil, popliteal angle, scarf sign, and heel to ear. Motor performance and reflexes are parts of
the behaviors in the Brazelton Neonatal Behavioral Assessment Scale.
- The nurse is teaching parents about the visual ability of their newborn. Which should the nurse
include in the teaching session? (Select all that apply.)
- Visual acuity is between 20/100 and 20/400.
- Tear glands do not begin to function until 8 to 12 weeks of age.
- Infants can momentarily fixate on a bright object that is within 8 inches.
- The infant demonstrates visual preferences of black-and-white contrasting patterns.
- The infant prefers bright colors (red, orange, blue) over medium colors (yellow, green, pink).
ANS: A, C, D
Visual acuity is reported to be between 20/100 and 20/400, depending on the vision
measurement techniques. The infant has the ability to momentarily fixate on a bright or moving
object that is within 20 cm (8 inches) and in the midline of the visual field. The infant
demonstrates visual preferences of black-and-white contrasting patterns. The visual preference is
for medium colors (yellow, green, pink) over dim or bright colors (red, orange, blue). Tear
glands begin to function until 2 to 4 weeks of age.
- Which assessments are included in the Apgar scoring system? (Select all that apply.)
- Heart rate
- Muscle tone
- Blood pressure
- Blood glucose
- Reflex irritability
ANS: A, B, E
The Apgar score is based on observation of heart rate, respiratory effort, muscle tone, reflex
irritability, and color. Blood pressure and blood glucose are not part of the Apgar scoring system.
- The nurse is completing a respiratory assessment on a newborn. What are normal findings of
the assessment the nurse should document? (Select all that apply.)
- Periodic breathing
- Respiratory rate of 40 breaths/min
- Wheezes on auscultation
- Apnea lasting 25 seconds
- Slight intercostal retractions
ANS: A, B, E
Periodic breathing is common in full-term newborns and consists of rapid, nonlabored
respirations followed by pauses of less than 20 seconds. The newborns respiratory rate is
between 30 and 60 breaths/min. The ribs are flexible, and slight intercostal retractions are normal
on inspiration. Periods of apnea lasting more than 20 seconds are abnormal, and wheezes should
- The nurse is instructing a new mother on safety measures for newborn abduction. Which
should the nurse include in the instructions? (Select all that apply.)
- Publish the birth announcement in your local newspaper.
- Dont relinquish the newborn to anyone without identification.
- Keep your door open if the newborn is in the room while you shower.
- Use a password system with the staff when the newborn is taken from the room.
- When you use the restroom, ring for a nurse to stay in the room with your newborn.
ANS: B, D, E
Safety measures to be taught to new mothers should include (1) not leaving the newborn alone in
the crib while taking a shower or using the bathroom; rather, they should ask to have the
newborn observed by a health care worker if a family member is not present in the room; (2) not
relinquishing the newborn to anyone without identification; and (3) using a password system
with the staff when the newborn is taken from the room as a routine security measure. The
newborn should not be left alone while the mother is showering, even if the door is left open. It
is recommended to not publish the birth announcement in the newspaper.
- The nurse is conducting discharge teaching to parents regarding care of the umbilical cord.
Which should the nurse include in the instructions? (Select all that apply.)
- Cover the umbilical cord with the diaper.
- The cord will fall off in 5 to 15 days.
- Clean around the umbilical cord stump with water.
- Watch for redness and drainage around the umbilical cord stump.
- A tub bath can be done every other day.
ANS: B, C, D
The umbilical cord is cleansed initially with sterile water or a neutral pH cleanser and then
subsequently with water. The stump deteriorates through the process of dry gangrene, with an
average separation time of 5 to 15 days. The umbilical cord area should be watched for redness
or drainage, which could indicate infection. The diaper is placed below the cord to avoid
irritation and wetness on the site, and tub bathing is not allowed until the umbilical cord falls off.
- A health care provider prescribes vitamin K intramuscular 1 mg one time within 1 hour of
birth. The medication label states: Vitamin K 2 mg/1 ml. The nurse prepares to administer one
dose. How many milliliters will the nurse prepare to administer one dose? Fill in the blank.
Record your answer to one decimal place.
Follow the formula for dosage calculation.
Volume = ml per dose
1 ml = 0.5 ml
Chapter 5 Guidelines for Breastfeeding
- 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?
- Break the suction by inserting your finger into the corner of the infants mouth.
- A popping sound occurs when the breast is correctly removed from the infants mouth.
Slowly remove the breast from the babys mouth when the infant has fallen asleep and
the jaws are relaxed.
Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the
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
- Which woman is most likely to continue breastfeeding beyond 6 months?
- A woman who avoids using bottles
- A woman who uses formula for every other feeding
- A woman who offers water or formula after breastfeeding
- A woman whose infant is satisfied for 4 hours after the feeding
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.
- In which condition is breastfeeding contraindicated?
- Triplet birth
- Flat or inverted nipples
- Human immunodeficiency virus infection
- Inactive, previously treated tuberculosis
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.
- Which type of formula should not be diluted before being administered to an infant?
- Ready to use
- Modified cows milk
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.
- How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed
infant need each day?
- 50 to 75
- 100 to 110
- 120 to 140
- 150 to 200
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
- How many milliliters per kilogram (mL/kg) of fluids does a newborn need daily for the first 3
to 5 days of life?
- 20 to 30
- 40 to 60
- 60 to 100
- 120 to 150
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.
- Which is the hormone necessary for milk production?
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.
- Which recommendation should the nurse make to a client to initiate the milk ejection reflex?
- Wear a well-fitting firm bra.
- Drink plenty of fluids.
- Place the infant to the breast.
- Apply cool packs to the breast.
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.
- Which is the first step in assisting the breastfeeding mother?
- Assess the womans knowledge of breastfeeding.
- Provide instruction on the composition of breast milk.
- Discuss the hormonal changes that trigger the milk ejection reflex.
- Help her obtain a comfortable position and place the infant to the breast.
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.
- Which is an important consideration in positioning a newborn for breastfeeding?
- Placing the infant at nipple level facing the breast
- Keeping the infants head slightly lower than the body
- Using the forefinger and middle finger to support the breast
- Limiting the amount of areola the infant takes into the mouth
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.
- 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?
- Unwrap and gently arouse the infant.
- Wait an hour and attempt to feed again.
- Try offering a bottle at the next feeding.
- Put the infant in the crib and try again later.
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.
- To prevent breast engorgement, what should the new breastfeeding mother be instructed to
- Feed her infant no more than every 4 hours.
- Limit her intake of fluids for the first few days.
- Apply cold packs to the breast prior to feeding.
- Breast-feed frequently and for adequate lengths of time.
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
- What is the difference between the aseptic and terminal methods of sterilization?
- The aseptic method requires a longer preparation time.
- The aseptic method does not require boiling of the bottles.
- The terminal method requires boiling water to be added to the formula.
- The terminal method sterilizes the prepared formula at the same time it sterilizes the equipment.
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.
- 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?
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.
- A new mother is concerned because her 1-day-old newborn is taking only 1 oz at each
feeding. What should the nurse explain?
- The infant is probably having difficulty adjusting to the formula.
- An infant does not require as much formula in the first few days of life.
- The infants stomach capacity is small at birth but will expand within a few days.
- The infant tires easily during the first few days but will gradually take more formula.
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.
- 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:
- more calcium.
- more calories.
- essential amino acids.
- important immunoglobulins.
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.
- 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?
- Early addition of baby food will meet the infants needs.
- The breast milk will gradually become richer to supply additional calories.
- As the infant requires more milk, feedings can be supplemented with cows milk.
- The mothers milk supply will increase as the infant demands more at each feeding.
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
- Which should the nurse recommend to the postpartum client to prevent nipple trauma?
- Assess the nipples before each feeding.
- Limit the feeding time to less than 5 minutes.
- Wash the nipples daily with mild soap and water.
- Position the infant so the nipple is far back in the mouth.
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.
- 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?
- This is a normal response in breastfeeding mothers.
- Notify your doctor so he can start you on antibiotics.
- Stop breastfeeding because you probably have an infection.
- Try massaging the area and apply heat; it is probably a plugged duct.
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.
- Which is an important consideration about the storage of breast milk?
- Can be thawed and refrozen
- Can be frozen for up to 2 months
- Should be stored only in glass bottles
- Can be kept refrigerated for 48 hours
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.
- What is the most serious consequence of propping an infants bottle?
- Dental caries
- Ear infections
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.
- A new mother asks why she has to open a new bottle of formula for each feeding. What is the
nurses best response?
- Formula may turn sour after it is opened.
- Bacteria can grow rapidly in warm milk.
- Formula loses some nutritional value once it is opened.
- This makes it easier to keep track of how much the baby is taking.
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.
- A new mother asks whether she should feed her newborn colostrum because it is not real
milk. The nurses best answer includes which information?
- Colostrum is unnecessary for newborns.
- Colostrum is high in antibodies, protein, vitamins, and minerals.
- Colostrum is lower in calories than milk and should be supplemented by formula.
Giving colostrum is important in helping the mother learn how to breast-feed before
she goes home.
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.
- 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?
- Fluid replacement should be based on weight and calculated in the range of 60 to 100 mL/kg.
- Offer additional water to tolerance in between infant feedings to maintain hydration.
- Give 12 ounces of fluid per feeding.
- No water is needed because formula and breast milk are adequate to maintain hydration.
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
- 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:
- tell the client to wear a bra at all times to provide more support to breast tissue.
- have the client put the infant to her breast more frequently.
- place ice packs on breast tissue after infant feeding.
explain that this is a normal finding and will resolve as her breast tissue becomes
more used to nursing.
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.
- 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:
- 10 and document findings in the chart.
- 6 and further teach and assist the mother in feeding activities.
- 5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.
- 8 and no further assistance is needed for feeding.
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.
- 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
Monitor the infants output; as long as at least six or more diapers are changed in a 24-hour period, that
should be sufficient.
Tell the mother that if a baby is satisfied with feeding, she or he will be content and not
Tell the mother that breast milk contains everything required for the infant and not to
worry about nutrition.
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.
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.
- A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once
her breast milk comes in. What is the nurses best response?
- Are you concerned about your ability to adequately nurse your baby?
- Do you eat a well-balanced diet, high in protein and carbohydrates?
- Breast milk is low in vitamin D and supplementation with 400 IU is recommended.
- Your breast milk has all the vitamins and will adequately meet your babys needs.
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.
- 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?
- I should encourage my baby to consume the entire amount of formula prepared for each feeding.
- I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.
- I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby.
- I will generally feed my baby every 3 to 4 hours or more as signs of hunger are displayed.
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.
- 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?
- Increase the rate of pitocin infusion to help spread out the contraction pattern.
- Place oxygen on the client at 8 to 10 L/min via face mask and turn the client to her left side.
- Stop the pitocin infusion.
- Call the physician to obtain an order for the initiation of magnesium sulfate.
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.
- 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
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.
- 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.)
- Flat nipples
- Cracked nipples
- Everted nipples
- Inverted nipples
- 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.
- Which interventions may relieve symptoms of colic in the infant? (Select all that apply.)
- Increased stimulation of infant to provide distraction
- Burping infant frequently during feedings
- Feeding infant placed in an upright position
- Providing chamomile tea to infant
- 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.
- For which infant should the nurse anticipate the use of soy formula? (Select all that apply.)
- Preterm infant
- Infant with galactosemia
- Infant with phenylketonuria
- Infant with lactase deficiency
- 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.
- 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.)
- Lip smacking
- Decrease in activity
- 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.
- The mother of a 7-month-old states, The baby is eating food now. Should I give him regular
milk, too? What is the nurses best response?
- You should give the baby low-fat milk.
- Try the milk. See if he has any digestive problems.
- Continue breast milk or iron-fortified formula until 1 year of age.
- At this age, infants can tolerate lactose-free or soy-based milk.
Whole milk should not be introduced before 1 year of age. Low-fat milk should not be
introduced before 2 years of age.
- The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. What does
self-feeding help to develop in the toddler?
- Good nutrition
- A sense of independence
- Adequate height and weight
- Healthy teeth
By the end of the second year, toddlers can feed themselves. This helps them to develop a sense
- The breastfeeding client whose recommended prepregnancy caloric intake was 2000 calories
per day would need how many calories per day to meet her current needs?
The increase for a breastfeeding client is 500 calories above her recommended prepregnancy
caloric intake. 2300 calories is not enough to meet her needs. 2750 calories may be too many
calories and may lead to weight gain. 3000 calories is too many for this client and will lead to
- Which client would require additional calories and nutrients?
- A 36-year-old female gravida 2, para 1, in her first trimester of pregnancy
- An 18-year-old female who delivered a 7-lb baby and is bottle feeding
- A 23-year-old female who had a cesarean section birth and is bottle feeding
- A 20-year-old female who had a vaginal birth 5 months ago and is breastfeeding
A client who is breastfeeding will require more calories and nutrients than individuals who are
pregnant, delivered regardless of the type of birth, and whether they are bottle feeding.
- Which client has correctly increased her caloric intake from her recommended pregnancy
intake to the amount necessary to sustain breastfeeding in the first 6 postpartum months?
- From 1800 to 2200 calories per day
- From 2000 to 2500 calories per day
- From 2200 to 2530 calories per day
- From 2500 to 2730 calories per day
The increased calories necessary for breastfeeding are 500, with 330 calories coming from
increased caloric intake and 170 calories from maternal stores. An increase of 230 calories is
insufficient for breastfeeding. An increase of 400 and 500 calories is above the recommended
- The nurse is teaching a breastfeeding client about substances to avoid while she is
breastfeeding. Which substances should the nurse include in the teaching session? (Select all that
- Omega-6 fatty acids
- Appetite suppressants
- Polyunsaturated omega-3 fatty acids
ANS: A, B, D
Foods high in caffeine should be limited. Infants of mothers who drink more than two or three
cups of caffeinated coffee or the equivalent each day may be irritable or have trouble sleeping.
Although the relaxing effect of alcohol was once thought to be helpful to the nursing mother, the
deleterious effects of alcohol are too important to consider this suggestion appropriate today. An
occasional single glass of an alcoholic beverage may not be harmful, but larger amounts may
interfere with the milk ejection reflex and may be harmful to the infant. Nursing mothers should
avoid appetite suppressants, which may pass into the milk and harm the infant. The long-chain
polyunsaturated omega-3 and omega-6 fatty acids are present in human milk. Therefore, they
should be included in the mothers diet during lactation.