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 A
Explanation
Choice A rationale
The lecithin/sphingomyelin (L/S) ratio test is a crucial assessment of fetal lung maturity. Lecithin and sphingomyelin are phospholipids that are components of surfactant, a substance vital for reducing surface tension in the alveoli and preventing lung collapse at birth. A ratio of 2: or greater generally indicates adequate lung maturity.
Choice B rationale
The L/S ratio test does not assess the baby's blood type. Fetal blood typing is determined through other methods, such as cordocentesis or maternal blood tests for fetal DNA, if clinically indicated. The L/S ratio specifically evaluates the quantity and ratio of pulmonary surfactants.
Choice C rationale
This test does not check the baby's liver development. Fetal liver development is assessed through different parameters, such as ultrasound visualization of liver size, blood flow characteristics, and specific liver enzyme levels if a concern exists. The L/S ratio is solely focused on pulmonary maturity.
Choice D rationale
The L/S ratio test is not used to check for genetic disorders. Genetic disorders are identified through chromosomal analysis, DNA sequencing, or biochemical tests performed on amniotic fluid cells obtained during amniocentesis, or through chorionic villus sampling. The L/S ratio is a physiological marker of lung readiness.
Correct Answer is D
Explanation
Choice A rationale
Hydrocodone is an opioid analgesic, but it is typically used for moderate to severe pain and is not commonly administered as a primary agent for severe active labor pain due to its slower onset and potential for more pronounced maternal and neonatal respiratory depression compared to other rapid-acting opioids.
Choice B rationale
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) primarily used for mild to moderate pain and inflammation. It is generally not effective enough for severe labor pain and is contraindicated in late pregnancy due to potential adverse effects on fetal circulation, such as premature closure of the ductus arteriosus.
Choice C rationale
Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering naloxone during active labor would reverse the effects of any pain medication given, exacerbating the client's pain and potentially precipitating opioid withdrawal symptoms, thus it is not an appropriate pain management strategy.
Choice D rationale
Fentanyl citrate is a potent, rapid-acting synthetic opioid analgesic commonly used for severe pain during active labor. Its quick onset and short duration of action make it suitable for intermittent administration, allowing for effective pain relief with a lower risk of prolonged neonatal respiratory depression compared to longer-acting opioids.
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