A nurse is caring for a newborn who is 72 hr old.

Vital signs

0900:

• Heart rate 160/min
• Respiratory rate 80/min
• Temperature 38.1° C (100.6° F)
• Oxygen saturation 97%

1000:

• Heart rate 167/min
• Respiratory rate 72/min
• Temperature 38°C (100.4°F)
• Oxygen saturation 97%

Medical History

0900:

A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin.

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

A. "I'll let my baby drain one breast at each feeding."

Rationale:

A. "I'll let my baby drain one breast at each feeding." This statement indicates understanding because allowing the baby to empty one breast at each feeding helps in relieving breast engorgement by effectively removing milk. It promotes better milk flow and prevents overproduction.

B. Feeding the baby every 2 hours is a common recommendation, but it may not specifically address breast engorgement management.

C. Cold compresses can help reduce discomfort from engorgement, but they should be applied after feeding, not before.

D. While herbal teas can sometimes provide relief for engorgement, this statement does not address the direct management of engorgement through breastfeeding techniques.

Rationale:

A. Green penile discharge is not a typical finding in genital herpes. Discharge associated with genital herpes is usually clear or cloudy and may be accompanied by pain or itching.

B. Influenza-like symptoms, such as fever, headache, muscle aches, and fatigue, are common manifestations of genital herpes. However, they are not specific to the condition and can occur with various viral infections.

C. Anuria, or the absence of urine production, is not associated with genital herpes. It is a symptom of renal dysfunction or urinary tract obstruction.

D. White- or flesh-colored papillary growths in the genital area, known as genital warts or condylomata acuminata, are a characteristic finding of genital herpes caused by HSV 2. These growths are typically painless but can cause itching or discomfort.