A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

"I won't wear a bra during the daytime.".

"I'll apply cold compresses 20 min before each feeding.".

"I'll feed my baby every 2 hours.".

"I will stop breastfeeding until I am done with the antibiotics.".

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Wearing a supportive bra can actually help to manage engorgement, so it's not recommended to avoid wearing one during the day.

Choice B rationale:

Cold compresses are typically applied after feeding to reduce swelling, not before. Applying them before might hinder the milk let-down reflex.

Choice C rationale:

Frequent feeding can help to alleviate engorgement by ensuring that the breasts are being emptied regularly.

Choice D rationale:

Stopping breastfeeding until finishing antibiotics is not advisable, as it can lead to decreased milk supply and potential issues with engorgement. Antibiotics prescribed by a healthcare provider are usually safe to take while breastfeeding, and interrupting breastfeeding can exacerbate the engorgement problem. This choice is not appropriate for managing breast engorgement and is therefore incorrect.

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Correct Answer is B

Explanation

A. This condition typically results from excessive loss of acid, often due to vomiting or diuretics. It is not the most likely concern in a cold environment with an infant who has been crying and kicking.

B. A cold environment can lead to nonshivering thermogenesis in newborns, where they metabolize brown fat to generate heat. This process can lead to increased lactic acid production, potentially causing metabolic acidosis. The infant's fatigue following crying and kicking may indicate that the body has expended significant energy to stay warm, making metabolic acidosis a priority concern.

C. While hunger could be a reason for crying, it is not the priority concern in this scenario where environmental cold and fatigue are present.

D. Overstimulation might cause crying, but the environmental cold and subsequent risk of metabolic acidosis are more critical concerns in this context.

A. Activate respiratory arrest procedures. B. Request an order for supplemental oxygen. C. Continue routine monitoring. D. Report the observation to the charge nurse immediately.

Correct Answer is C

Explanation

Choice A rationale:

Activating respiratory arrest procedures is not necessary in this situation. The newborn's respiratory rate, although slightly elevated, does not indicate respiratory arrest. Instead, such procedures are reserved for situations where the newborn has stopped breathing or is in acute respiratory distress.

Choice B rationale:

Requesting an order for supplemental oxygen may be premature. The newborn's respiration rate of 44/min, although shallow with periods of apnea, is still within the normal range for a newborn. Providing supplemental oxygen should be considered when the newborn is showing signs of significant respiratory distress or if oxygen saturation levels are low.

Choice C rationale:

The most appropriate action in this scenario is to continue routine monitoring of the newborn's respiratory rate and overall condition. Newborns often exhibit irregular breathing patterns, including periods of apnea, especially in the first few hours after birth. As long as the newborn's color, heart rate, and overall appearance are stable, routine monitoring is appropriate.

Choice D rationale:

There is no need to report the observation to the charge nurse immediately, as the newborn's respiratory rate and pattern fall within the expected range for a 12-hour-old newborn.

Reporting should be considered when there are significant deviations from the norm or if the newborn's condition deteriorates.

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A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired.”. What is the nurse's priority concern?

Correct Answer is B

Explanation

A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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The nurse is most concerned about which assessment finding?

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A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

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