A nurse is assessing a full-term newborn upon admission to the nursery. What clinical findings should the nurse report?

Choice A rationale
While assessing the client’s kidney function is important in general, it is not the best way to evaluate medication adherence. Kidney function can affect the metabolism and excretion of medications, but it does not directly indicate whether the client is taking their medication as prescribed.
Choice B rationale

Correct answer. Checking the client’s serum medication level is the most direct and reliable way to evaluate medication adherence. If the client is taking the medication as prescribed, the serum medication level should be within the therapeutic range.
Choice C rationale
Determining the client’s apical pulse rate can provide information about the client’s overall cardiovascular status and can indicate certain drug effects or side effects, but it does not directly measure medication adherence.
Choice D rationale
Asking the client if they are taking the medication as prescribed can provide useful information, but it relies on self-report, which may not be reliable. Some clients might forget doses or not take the medication exactly as prescribed.

Choice A rationale
This is the correct answer. Sore nipples are a common issue for breastfeeding women, often due to the baby not latching well. Assessing the newborn’s latch can help identify and correct any issues, potentially alleviating the mother’s discomfort.
Choice B rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended as it may not provide enough feeding time for the baby and could potentially exacerbate nipple soreness.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended. Newborns typically need to feed every 2-3 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings is not typically the first step in addressing sore nipples in a breastfeeding mother. It’s more important to address the underlying issue, such as improving the baby’s latch.