A nurse is assisting a teenage client with breastfeeding.
The client asks, "How will I know when to feed my baby?" The nurse educates the client on infant feeding cues. Which of the following is a newborn feeding cue?
The baby will sneeze.
The baby will move their legs in a bicycle motion.
The baby will put their hand to their mouth.
The baby will extend both arms to the side of their body.
The baby will extend both arms to the side of their body.
The Correct Answer is C
Choice A rationale
Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.
Choice B rationale
Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.
Choice C rationale
Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.
Choice D rationale
Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.
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Correct Answer is C
Explanation
Choice A rationale
A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.
Choice B rationale
When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.
Choice C rationale
Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.
Choice D rationale
Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.
Correct Answer is C
Explanation
Choice A rationale
A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms
of preeclampsia appear.
Choice B rationale
A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.
Choice C rationale
A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.
Choice D rationale
A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.