A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client's heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms?

The correct answer is choice A. “The more my baby is at the breast sucking, the more milk I will produce.” This statement indicates an understanding of the teaching because it reflects the principle of supply and demand in breastfeeding. The more the baby stimulates the breast, the more milk the mother will produce.

Choice B is wrong because manually expressing milk will not decrease the milk supply. In fact, it can help increase the milk supply by removing more milk from the breast and signaling the body to make more.

Choice C is wrong because the breast is not emptied after 5 to 10 minutes of feeding. The baby should be allowed to nurse until they are satisfied and show signs of fullness, such as releasing the nipple, falling asleep, or turning away from the breast. The average duration of a feeding session can vary from 10 to 45 minutes.

Choice D is wrong because the baby should not always start on the same breast when feeding. The mother should alternate which breast she offers first to ensure both breasts are stimulated and drained equally.

This can help prevent engorgement, mastitis, and low milk supply. A simple way to remember which breast to start with is to wear a bracelet or a clip on the bra strap on the side that needs to be offered next.

Choice A reason:

Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.

Choice B reason:

Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.

After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.

Choice C reason:

Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.

Choice D reason:

Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.