A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:
has at least six to eight wet diapers per day.
has at least one breast milk stool every 24 hours.
sleeps for 6 hours at a time between feedings.
gains 1 to 2 ounces per week.
The Correct Answer is A
Choice A reason:
Choice A is the correct answer because the number of wet diapers a newborn has per day is a reliable indicator of effective breastfeeding. When a baby is breastfeeding well and getting enough milk, they will have an adequate number of wet diapers, typically at least six to eight per day. The frequent wet diapers indicate that the baby is adequately hydrated, and their body is eliminating waste products as expected.
Choice B reason:
Choice B, having at least one breast milk stool every 24 hours, is not the most reliable indicator of effective breastfeeding, although it is an important consideration. The frequency of bowel movements can vary among breastfed infants, and some babies may have several bowel movements a day, while others may have fewer, even skipping a day. The number of wet diapers is a more consistent measure of sufficient milk intake.
Choice C reason:
Choice C, sleeping for 6 hours at a time between feedings, is not an accurate indicator of effective breastfeeding in a 4-day-old newborn. Newborns typically feed frequently, at least 8-12 times in 24 hours, and they may not sleep for extended periods between feedings at this age. Frequent feeding is essential for establishing a good milk supply and ensuring the baby receives enough nutrients.
Choice D reason:
Choice D, gaining 1 to 2 ounces per week, is also not the most reliable indicator of effective breastfeeding in the early days after birth. Weight gain can vary significantly in newborns, and a 4-day-old baby might not show the expected 1 to 2 ounces per week gain yet. Moreover, weight gain can be affected by factors other than breastfeeding, such as birth weight, initial fluid loss, and individual growth patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Rupture of the membranes is not a reliable sign of true labor, as it can occur before or during labor, or be artificially induced by the provider. • Choice B reason:
Patterns of contractions can vary depending on the stage and phase of labor, and can also be influenced by factors such as hydration, activity, and medication. Contractions alone do not indicate true labor unless they are accompanied by cervical changes. • Choice C reason:
Changes in the cervix, such as effacement (thinning) and dilation (opening), are the most accurate indication of true labor. Cervical changes are caused by the pressure of the presenting part and the force of the contractions. The nurse should assess the cervix periodically to determine the progress of labor. • Choice D reason:
The station of the presenting part refers to the relationship of the fetal head to the maternal ischial spines, which are bony landmarks in the pelvis. The station can range from -5 (high) to +5 (low), with 0 being at the level of the ischial spines. Station does not indicate true labor, as it can vary depending on the parity, pelvic shape, and fetal position of the client.
Correct Answer is C
Explanation
Choice A reason:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
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