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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should administer scheduled pain medications to a client who is near death. This is an important nursing intervention to ensure that the client is comfortable and free from pain.
b) Providing oral care every 6 hours is important, but it may not be the highest priority for a client who is near death.
c) Administering liquids using a syringe may not be necessary or appropriate for a client who is near death.
d) Whispering when talking to family members is not necessary. The nurse should communicate openly and honestly with the family members.
Correct Answer is A
Explanation
After a patient dies, postmortem care includes preparing them for family viewing . The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood setling in the face.
The other options are not correct because:
b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.
c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth.
d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .
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