A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum.
Which of the following information should the nurse include in the teaching?
Your baby's urine should appear dark and concentrated.
Your breasts should stay firm after the baby breastfeeds.
You should feel a tugging sensation when the baby is sucking.
You should expect your baby to have two to three wet diapers in a 24-hour period.
The Correct Answer is C
Choice A rationale
Dark and concentrated urine in an infant indicates inadequate hydration, which can be a sign of insufficient milk intake during breastfeeding. Well-hydrated infants, receiving adequate breast milk, typically produce urine that is pale yellow and dilute, not dark and concentrated. This reflects proper kidney function and fluid balance.
Choice B rationale
After effective breastfeeding, the breasts should feel softer and less engorged, not firm. The firmness before feeding is due to milk accumulation within the mammary glands. As the infant removes milk, the pressure decreases, leading to a softer breast texture, indicating successful milk transfer.
Choice C rationale
A tugging sensation during breastfeeding is a normal and expected physiological sign. This sensation results from the baby's effective latch and negative pressure creation, which draws milk from the milk ducts into the baby's mouth. It signifies proper milk ejection and efficient feeding.
Choice D rationale
Two to three wet diapers in a 24-hour period for a 5-day-old infant is indicative of insufficient fluid intake. A well-hydrated newborn at this age, receiving adequate breast milk, should typically have six to eight wet diapers per 24 hours, reflecting sufficient hydration and milk transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Group B Streptococcus (GBS) screening is typically performed much later in pregnancy, usually between 35 and 37 weeks of gestation. This screening is crucial for identifying carriers and administering prophylactic antibiotics during labor to prevent vertical transmission to the newborn, which can cause severe infections like sepsis or meningitis.
Choice B rationale
Human immunodeficiency virus (HIV) screening is a standard diagnostic test offered to all pregnant clients during their first prenatal visit, typically around 12 weeks of gestation. Early detection allows for timely interventions, such as antiretroviral therapy, to reduce the risk of mother-to-child transmission and improve maternal health outcomes.
Choice C rationale
Chorionic villus sampling (CVS) is an invasive diagnostic procedure performed earlier in pregnancy, usually between 10 and 13 weeks of gestation, but it is not a routine screening test. It is typically offered to clients at high risk for genetic disorders due to family history, advanced maternal age, or abnormal prenatal screening results.
Choice D rationale
Cervical cone biopsy is a diagnostic and therapeutic procedure used to remove a cone-shaped piece of tissue from the cervix, typically to evaluate or treat abnormal cervical cells. It is not a routine diagnostic test during a normal prenatal visit and is usually performed prior to pregnancy or if there are specific gynecological concerns.
Correct Answer is C
Explanation
Choice A rationale
Immediate cesarean birth is generally not indicated for intrauterine fetal demise unless there are maternal complications, such as hemorrhage or infection, or if the client has a prior uterine scar that contraindicates vaginal birth. Cesarean section carries higher risks for the mother compared to vaginal delivery and is usually reserved for specific obstetrical indications.
Choice B rationale
Methotrexate is an antimetabolite medication primarily used in the management of ectopic pregnancy or gestational trophoblastic disease due to its cytotoxic effects on rapidly dividing cells. It is not indicated for the induction of labor or expulsion of a fetus in cases of intrauterine fetal demise as it does not stimulate uterine contractions effectively for this purpose.
Choice C rationale
In cases of intrauterine fetal demise at 36 weeks of gestation, scheduled induction of labor is the most common and generally recommended treatment option. This approach allows for planned delivery, reduces the psychological burden of carrying a deceased fetus, and minimizes the risk of complications such as coagulopathy for the mother, typically occurring after prolonged retention.
Choice D rationale
Dilation with suction curettage is a procedure typically used for early pregnancy termination or management of miscarriage in the first or early second trimester. At 36 weeks of gestation, the size of the fetus and uterus makes this procedure unsafe and inappropriate for delivery of a deceased fetus, posing significant risks of uterine perforation or hemorrhage.
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