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 C
Explanation
Answer: C
Rationale:
A) Encourage strength-training exercise: Strength-training exercises can be beneficial in building muscle mass and improving overall strength. However, for a client with leukemia experiencing chronic fatigue, this may be too strenuous and could exacerbate their fatigue rather than alleviate it. It is better to encourage light to moderate activities based on their tolerance.
B) Increase the client's fluids to 4 L per day: While adequate hydration is important, increasing fluids to 4 L per day may not be suitable for all clients and could pose risks, particularly if there are concerns about fluid balance or renal function. This recommendation should be tailored to the client's specific needs and medical condition.
C) Increase protein in the diet: Increasing protein in the diet can help improve energy levels and support the body's repair and regeneration processes. For clients with leukemia who are experiencing chronic fatigue, a high-protein diet can aid in maintaining muscle mass and overall nutritional status, helping to combat fatigue.
D) Encourage the client to have continual bed rest: Encouraging continual bed rest can lead to deconditioning and further exacerbate fatigue. It is important to balance rest with periods of gentle activity to maintain some level of physical function and avoid complications such as muscle atrophy or deep vein thrombosis.
Correct Answer is ["A","B","E"]
Explanation
Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood flow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.
Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood flow due to increased pressure within the compartment.
Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,
which can be a sign of compartment syndrome.
Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inflammation or infection.
Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.
Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.
By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.
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