A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?

Correct Answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective.

Correct Answer: A

Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers.

Correct Answer: A

Rationale: The correct answer is A. Home pregnancy tests detect hCG, a hormone produced during pregnancy, and are most accurate after the first missed period when hCG levels are higher. Testing too early may result in a false negative. Waiting until after the first missed period increases the reliability of the test results.

Correct Answer: B

Rationale: The correct answer to the question is option B: "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." This response is the most appropriate because it addresses a key indicator of adequate breast milk intake in infants. In the early days of breastfeeding, new mothers often worry about whether their baby is getting enough milk. The frequency and color of a baby's urine can be a reliable indicator of proper hydration and milk intake. Pale straw-colored urine indicates that the baby is well-hydrated, which is directly linked to adequate milk consumption. Option A, weighing the baby daily, can be misleading as weight gain alone is not always a direct indicator of successful breastfeeding. Some babies may have variations in weight gain due to factors other than milk intake. Option C suggesting offering extra bottle milk can interfere with establishing a proper breastfeeding routine and can lead to overfeeding. Option D recommending bottle feeding as a solution undermines the benefits of breastfeeding and does not address the mother's concerns effectively. In the educational context, it is crucial for nurses to provide evidence-based information to support mothers in their breastfeeding journey. Understanding the signs of adequate milk intake is essential for new mothers to gain confidence in their breastfeeding experience. By explaining the significance of urine color as an indicator of hydration and milk intake, nurses can empower mothers to trust their bodies and continue breastfeeding successfully.

Correct Answer: B

Rationale: In the context of maternal behavior when a new mother first receives her infant, option B is correct. This option describes the typical behavior of a mother tracing the infant's profile with her fingertips after receiving the infant in her arms. This behavior reflects the maternal instinct to bond with and explore the newborn. Option A is incorrect because undressing and examining the infant completely is not a typical immediate response upon first receiving the baby. Option C is incorrect as it solely mentions cuddling without the specific action of tracing the infant's profile with her fingertips. Option D is incorrect because it lacks the detailed action of tracing the infant's profile, which is a significant part of the initial bonding process between mother and baby. From an educational perspective, understanding the initial behaviors of new mothers when they first receive their infants is crucial for healthcare providers working with postpartum women. This knowledge helps in providing appropriate support and guidance to facilitate the bonding process between mother and baby, which is essential for the overall well-being of both the mother and the newborn.