Physiological Integrity: Basic Care and Comfort-Nutrition
21. A nurse prepares to give maternal breast milk to an infant via a bottle. Which steps should the nurse take when preparing and administering breast milk? Select all that apply and place in priority order.
. Review the diet orders.
. Compare the infant's identification band against the label on the milk.
. Discard thawed milk after 1 hour.
. Thaw frozen milk slowly in the microwave.
. Put on gloves.
Test-Taking Tip
Breast milk is a body fluid that has the potential for transmitting infectious disease. A nurse should take similar steps as when administering blood products, including confirming the "five rights," and following standard precautions.
Content Area: Child Health, Nutrition; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration
Physiological Integrity: Basic Care and Comfort-Nutrition
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Answer 1 is correct because the first step is to confirm the diet order. Answer 2 is correct because the second step should be to verify that the correct client is receiving the breast milk. Answer 3 is correct because the final step is to discard thawed breast milk after 1 hour. Answer 4 is incorrect because breast milk should never be warmed in the microwave; this destroys the immune properties and creates hot spots in the bottle, which could burn the infant. Answer 5 is correct because the third step is to put on gloves, since breast milk is a body fluid and may be a route of exposure to infectious organisms. Universal precautions (applying protective barriers such as gloves, gowns, and mask) should be applied when handling blood or body fluids.