Answer to Question 1
ANS: A
At 1 week of age, an infant's stomach has a capacity of about 90 mL. Attempting to feed 120 mL is too much at one time. Weighing the baby and plotting her growth and having the mother demonstrate feeding and burping techniques are not incorrect, but the mother needs additional information to safely feed her baby. Simply reassuring the mother does not give her the information she needs to feed the baby appropriately.
Answer to Question 2
ANS: D
Jaundice that appears within the first 24 hours of life is considered pathological. Causes can include events that lead to excessive breakdown of RBCs, leading to increased bilirubin levels, such as polycythemia, traumatic birth, infection, metabolic disorders, and Rh incompatibility. The diagnosis is made when total serum bilirubin levels rise higher than 12.9 mg/dL in term infants and 15 mg/dL in preterm infants. The nurse should review the chart for evidence of a traumatic birth. The other actions are not warranted.