A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding effectively?
Falls asleep 5 minutes after starting a feeding
Has 3 wet diapers each day.
Has a bowel movement every other day.
Makes audible swallowing sounds.
The Correct Answer is D
The nurse should identify that the newborn is making audible swallowing sounds as an indication that they are breastfeeding effectively. This indicates that the newborn is able to latch onto the breast and transfer milk effectively.
a) Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not getting enough milk.
b) Having 3 wet diapers each day is not enough for a 5-day-old newborn. A newborn should have at least 6 wet diapers per day.
c) Having a bowel movement every other day is not an indication of effective breastfeeding. A breastfed newborn should have at least 3 bowel movements per day.
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Related Questions
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.
Correct Answer is A
Explanation
a . Provide a tour of the perioperative area prior to surgery.
The correct answer is a. Provide a tour of the perioperative area prior to surgery.
Explanation:
When caring for an adolescent scheduled for surgery, providing a tour of the perioperative area prior to the procedure is an important action for the nurse to take. Adolescents may experience fear and anxiety related to the unfamiliar environment and procedures associated with surgery. Providing a tour allows the adolescent to become familiar with the surroundings, equipment, and healthcare team, which can help alleviate anxiety and promote a sense of control.
Explanation for the other options:
b. Explain that anesthesia is a special type of sleep: While it is important to provide information about anesthesia to the adolescent, describing it as a "special type of sleep" may be misleading. Anesthesia is a medical procedure that involves more than just being asleep, and it is important to provide accurate information to the adolescent.
c. Keep medical equipment out of the client's sight: While it is important to create a comfortable and non- threatening environment for the adolescent, completely hiding medical equipment may not be feasible or necessary. Instead, the nurse should address any specific fears or concerns the adolescent may have and provide age-appropriate explanations and reassurance.
d. Wait until after surgery to explain the importance of coughing and deep breathing: It is important to provide preoperative education to the adolescent to promote their understanding and cooperation. Explaining the importance of coughing and deep breathing before surgery helps the adolescent prepare and participate in their own recovery. Waiting until after surgery may result in missed opportunities for early postoperative interventions.
In summary, providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control.
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