A newborn is reported to have breastfed very well during the first successful feeding after birth.
The baby is now 4 hours old and has not had a second feeding.
The nurse would:
Advise the mother to stop nursing and offer formula.
Teach the mother to pump her breast.
Advise the mother to discuss this with the newborn's pediatrician.
Teach about newborn sleep and hunger patterns.
The Correct Answer is D
Choice A rationale
It is important to encourage breastfeeding rather than offering formula, especially if the mother wishes to breastfeed.
Choice B rationale
Pumping is not necessary at this time as the baby is just 4 hours old and establishing feeding patterns.
Choice C rationale
Consulting the pediatrician is not immediately necessary for this situation.
Choice D rationale
Teaching the mother about newborn sleep and hunger patterns is appropriate, as newborns often have irregular feeding schedules in the first few days. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Respiratory assessment is vital, especially following childbirth, to ensure the mother is not experiencing respiratory issues.
Choice B rationale
Monitoring hemoglobin levels can help identify significant blood loss during delivery, which can lead to anemia and other complications.
Choice C rationale
A heart rate that is elevated postpartum may indicate underlying issues such as infection or hemorrhage, which need to be reported.
Choice D rationale
Continuous blood trickling from the vagina is a warning sign of potential postpartum hemorrhage, which is a medical emergency.
Correct Answer is B
Explanation
Choice A rationale
Swelling of the labia postpartum can be a common occurrence due to trauma during delivery and does not specifically indicate the need to urinate. The swelling usually subsides with time and proper postpartum care.
Choice B rationale
A fundus positioned three fingerbreadths above the umbilicus can indicate a full bladder. The bladder's distension prevents the uterus from contracting properly, which can lead to postpartum hemorrhage and other complications, hence the need for the client to urinate.
Choice C rationale
Moderate lochia rubra is a normal finding in the postpartum period and does not specifically indicate the need to urinate. Lochia changes in color and amount over the postpartum weeks as the uterus heals.
Choice D rationale
Swelling of the ankles and feet, or edema, is common postpartum due to the body's adjustment to changes in blood volume and fluid shifts. It does not directly indicate the need to urinate.
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