Exhibits

Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.

A. Heat loss. Newborns are highly susceptible to heat loss due to their large surface area relative to body weight and limited ability to generate heat. Cold stress can lead to hypoglycemia, respiratory distress, and metabolic acidosis. To prevent this, the nurse should dry the newborn thoroughly, provide skin-to-skin contact, and use a radiant warmer or warm blankets immediately after birth.
B. Fluid balance. While newborns require close monitoring of fluid balance, they are born with sufficient fluid stores. Dehydration is not an immediate concern within the first few minutes of life. Initial interventions focus on thermoregulation and establishing respiration.
C. Bleeding tendencies. Newborns have low vitamin K levels, which increase the risk of bleeding. However, vitamin K prophylaxis is given within the first hour after birth and is not the immediate priority over establishing adequate oxygenation and thermoregulation.
D. Hypoglycemia. Hypoglycemia is a concern, especially in infants of diabetic mothers or those with low birth weight. However, preventing heat loss is a higher priority, as cold stress can contribute to hypoglycemia. Once thermoregulation is established, glucose monitoring can be performed as needed.

A. Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B. Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C. Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D. Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E. Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F. Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G. Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.