A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

"I should crush cabbage leaves and place them on my breast.".

"I will wear a snug-fitting bra.".

"I should stimulate my nipples by squeezing softly.".

"I will apply ice packs to my breasts.".

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.

Choice B rationale:

Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.

Choice C rationale:

Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.

Choice D rationale:

Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.

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Correct Answer is D

Explanation

A. Back to sleep: While placing babies on their backs to sleep is essential for reducing the risk of sudden infant death syndrome (SIDS), it does not prevent flat spots. Instead, tummy time while the baby is awake helps balance the time spent on their back.

B. Take the baby for walks: Taking a baby for walks is beneficial for overall development and stimulation but does not directly prevent flat spots on the head.

C. Keep them awake most of the day: This is not a safe or recommended practice. Babies need sufficient sleep for proper growth and development.

D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.

A. Respiratory distress. B. Hyperglycemia. C. Metabolic alkalosis. D. Hypoglycemia.

Correct Answer is ["A","D"]

Explanation

Choice A rationale:

Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.

Choice B rationale:

Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.

Choice C rationale:

Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.

Choice D rationale:

Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.

Choice E rationale:

Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.

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A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How do you prevent flat spots on the back of a baby's head?

Correct Answer is D

Explanation

D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

Correct Answer is ["A","D"]

Explanation

A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

A mother who is holding her 2-hour-old newborn says, "I don't think she likes breastfeeding, but last time, when we were in the delivery room, she did really well.”. Which is the nurse's best response?

Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a parent about using an iron-fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching?