A nurse is teaching a new parent about breastfeeding her 2-week-old infant.
Which of the following statements by the parent indicates an understanding of the teaching?
“The more my baby is at the breast sucking, the more milk I will produce.”.
“Manually expressing my milk will decrease my milk supply
"After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.”.
“My baby should always start on the same breast when feeding.”
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The client is observed displaying a shuffling gait while walking in the hall is the correct answer. The nurse should recognize that observing a shuffling gait in a client who is taking antipsychotic medication is an adverse effect that must be reported to the healthcare provider. A shuffling gait is a movement disorder known as parkinsonism, which can be a side effect of some antipsychotic medications, particularly first-generation or typical antipsychotics.
Parkinsonism includes symptoms similar to Parkinson's disease, such as a shuffling walk, muscle stiffness, tremors, and difficulty with balance and coordination. It can occur as a result of blocking dopamine receptors in the brain, leading to an imbalance in dopamine levels.
Choice B reason:
The client mumbling quietly while alone is not correct because in the day room may be related to the symptoms of schizophrenia, and it does not indicate an adverse effect of the antipsychotic medication.
Choice C reason:
The client feeling light-headed when standing up quickly is not correct and it may be related to postural hypotension, which can be a side effect of some antipsychotic medications. While it should be monitored and reported if persistent or severe, it is not as urgent as reporting a shuffling gait.
Choice D reason:
The client stating that being in the sun hurts their eyes does not necessarily indicate an adverse effect of the antipsychotic medication. It may be related to other factors or unrelated to the medication.
Correct Answer is D
Explanation
The correct answer is choice B. A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
Therefore, the nurse should monitor the client’s fluid intake, renal function, and serum electrolytes before and after the colonoscopy.
Choice A is wrong because a client who received a Mantoux test 48 hours ago and has an induration does not necessarily require follow-up care. A Mantoux test is a skin test that detects infection by Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). The test involves injecting a small amount of tuberculin purified protein derivative (PPD) into the skin and measuring the size of the induration (firm swelling) after 48 to 72 hours. The interpretation of the test result depends on the size of the induration and the risk factors of the client for TB infection or disease. For example, an induration of 5 mm or more is considered positive in people living with HIV, recent contacts of infectious TB cases, or people with chest x-ray findings suggestive of previous TB disease. However, an induration of 15 mm or more is considered positive in people with no known risk factors for TB.
Therefore, the nurse should assess the client’s history and risk factors before determining whether the Mantoux test result requires follow-up care.
Choice C is wrong because a client who is taking bumetanide and has a potassium level of 3.6 mEq/L does not require follow-up care.
Bumetanide is a loop diuretic that lowers blood pressure by increasing urine output and reducing fluid retention. However, it can also cause hypokalemia (low potassium levels) as a side effect. The normal range for serum potassium is 3.5 to 5.0 mEq/L, so a level of 3.6 mEq/L is within the normal range and does not indicate hypokalemia.
Therefore, the nurse does not need to intervene for this client.
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