A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?

Offer the newborn 30 mL (1 oz) of water between feedings.

Allow the baby to feed at least every 3 hr.

Feed the newborn 5 to 10 min per breast.

Expect two to four wet diapers every 24 hr.

Answer and Explanation

The Correct Answer is B

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Correct Answer is D

Explanation

The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”

Choice A rationale:

The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.

Choice B rationale:

An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.

Choice C rationale:

Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.

Choice D rationale:

Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.

A. Have the client limit the length of breastfeeding to 5 min per breast. B. Offer supplemental formula between the newborn's feedings. C. Assess the newborn's latch while breastfeeding. D. Instruct the client to wait 4 hr between daytime feedings.

Correct Answer is C

Explanation

Choice A rationale:
Limiting the length of breastfeeding to 5 minutes per breast may not address the underlying issue of sore nipples and can compromise the newborn's nutritional intake and bonding with the mother.

Choice B rationale:
Offering supplemental formula between feedings is not indicated unless there are specific concerns about the newborn's weight gain or nutritional needs. It does not directly address the issue of sore nipples.

Choice C rationale:
Assessing the newborn's latch while breastfeeding is essential to identify if improper latch or positioning is causing sore nipples. Correcting the latch technique can alleviate the discomfort and promote effective breastfeeding.

Choice D rationale:
Instructing the client to wait 4 hours between daytime feedings may lead to inadequate feeding for the newborn, especially during the early postpartum period when frequent feedings are essential for establishing breastfeeding and ensuring proper milk supply.

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A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

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