A nurse is reinforcing discharge instructions about breastfeeding with a client. Which of the following statements should the nurse make?
"You should recognize that your baby sucking on his hands is a hunger cue."
"You should feed your baby for 10 minutes on each breast.”
"You should feed your baby six times a day."
"You should wake your baby at least every 6 hours at night for feedings."
The Correct Answer is A
(A) "You should recognize that your baby sucking on his hands is a hunger cue."
Recognizing hunger cues is crucial for successful breastfeeding. Early hunger cues like sucking on hands, rooting, and lip-smacking indicate that the baby is ready to feed. Responding to these cues can help establish a good breastfeeding routine and ensure the baby gets adequate nutrition before becoming too distressed to feed effectively.
(B) "You should feed your baby for 10 minutes on each breast."
Feeding duration can vary significantly among babies. Some may need longer than 10 minutes on each breast, while others might feed more efficiently in a shorter time. Instead of a strict time limit, it's important to encourage the mother to allow the baby to feed until they show signs of being full, such as pulling away from the breast or falling asleep.
(C) "You should feed your baby six times a day."
Newborns typically need to feed more frequently than six times a day. Most newborns breastfeed 8-12 times in 24 hours. Limiting feeds to six times a day may not provide sufficient nutrition and can affect the baby’s growth and milk supply.
(D) "You should wake your baby at least every 6 hours at night for feedings."
Newborns, especially in the first few weeks, often need to be fed more frequently than every 6 hours, including at night. Typically, it’s recommended to wake a baby to feed if they sleep for more than 4 hours at a time in the early weeks to ensure adequate intake and to help establish the mother’s milk supply.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) Maternal temperature 36.3°C (101°F):
While maternal temperature elevation can indicate infection, in this scenario, the sudden gush of vaginal fluid takes precedence as it could be indicative of premature rupture of membranes. However, assessing maternal temperature is important for ruling out maternal infection, but it is not the priority manifestation compared to assessing fetal well-being.
(B) Amniotic fluid with meconium noted:
While the presence of meconium in the amniotic fluid is concerning, assessing fetal heart tones is the priority. Meconium-stained amniotic fluid can indicate fetal distress, but the immediate concern is to determine if the fetus is experiencing any compromise or distress by assessing the fetal heart rate.
(C) Fetal heart tones 98/min:
In this scenario, the priority is to assess the well-being of the fetus. Fetal heart tones provide critical information about fetal status, indicating whether the baby is experiencing any distress or compromise. A fetal heart rate of 98 beats per minute (bpm) is within the normal range for a fetus at 34 weeks of gestation. However, any abnormalities or significant deviations from the normal fetal heart rate range may indicate fetal distress, requiring immediate intervention.
(D) Foul-smelling vaginal discharge:
Foul-smelling vaginal discharge can indicate infection, such as chorioamnionitis, which is a concern during pregnancy. However, in this scenario, assessing fetal well-being takes precedence as it is essential to ensure timely interventions to assess and manage any fetal distress.
Correct Answer is B
Explanation
Answer: B. Determine the newborn's respiratory rate.
Rationale:
A. Weigh the newborn's wet diaper:
While monitoring fluid output is important in assessing hydration status and overall health, it is not the immediate priority. In the context of a newborn with neonatal abstinence syndrome (NAS), the respiratory status takes precedence, especially given that withdrawal can affect respiratory function.
B. Determine the newborn's respiratory rate:
Assessing the respiratory rate is crucial, as newborns with NAS may experience respiratory distress, including increased respiratory effort or apnea. Identifying any respiratory issues early allows for prompt intervention, which is vital for the newborn's safety and well-being. Ensuring adequate respiratory function is a priority in this population.
C. Auscultate the newborn's bowel sounds:
While assessing bowel sounds is relevant to monitoring gastrointestinal function and potential withdrawal symptoms, it is not the immediate priority. Changes in bowel sounds may occur due to the syndrome, but respiratory assessment should come first to ensure stability.
D. Swaddle the newborn in blankets:
Swaddling can provide comfort to a newborn with NAS; however, it is not the first action to take. Comfort measures are important, but they should follow critical assessments of the newborn's respiratory and overall clinical status to ensure safety.
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