A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse perform to assess the amount of drainage?

Mark the drainage output on the collection chamber every 48 hours.

Strip the chest tube vigorously to dislodge blood clots.

Maintain the collection chamber below the client’s chest.

Add water to the water seal chamber as it evaporates.

Answer and Explanation

The Correct Answer is C

Choice A reason: Marking drainage output every 48 hours is too infrequent to accurately assess drainage in a closed wound drainage system. Frequent monitoring (e.g., every shift) is needed to track output, detect complications like excessive bleeding, and ensure system functionality, making this intervention inadequate for assessment.
Choice B reason: Stripping the chest tube vigorously is not recommended, as it can increase intrathoracic pressure, risking tissue damage or bleeding. It does not assess drainage amount but manipulates the tube, potentially causing harm. Assessment requires observing output in the collection chamber, making this action incorrect.
Choice C reason: Maintaining the collection chamber below the client’s chest ensures proper drainage by gravity in a closed wound drainage system, like a chest tube. This position prevents backflow and allows accurate measurement of drainage output in the chamber, essential for assessing fluid loss and detecting complications like hemothorax.
Choice D reason: Adding water to the water seal chamber maintains system function but does not directly assess drainage amount. The water seal prevents air re-entry, not measures output. Assessment involves observing and recording drainage in the collection chamber, making this action irrelevant to the question’s focus.

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Correct Answer is A

Explanation

Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.

A. Contractions lasting 60 seconds every 5 minutes. B. Fetal heart rate (FHR) of 140 beats per minute. C. Maternal blood pressure of 120/80 mmHg. D. Late decelerations in the FHR.

Correct Answer is D

Explanation

Choice A reason: Contractions lasting 60 seconds every 5 minutes are normal for active labor, indicating effective uterine activity to progress delivery. This does not require immediate reporting, as it aligns with expected labor patterns and does not indicate fetal or maternal distress, making it a non-urgent finding.
Choice B reason: A fetal heart rate of 140 beats per minute is within the normal range (110-160 bpm) for a fetus in labor. This indicates fetal well-being and does not require reporting unless accompanied by abnormal patterns like decelerations, making this finding normal and not urgent.
Choice C reason: A maternal blood pressure of 120/80 mmHg is normal and does not indicate distress or complications like preeclampsia. It does not require reporting, as it reflects stable maternal hemodynamics during labor, making this finding non-urgent compared to fetal heart rate abnormalities.
Choice D reason: Late decelerations in the FHR indicate uteroplacental insufficiency, reducing fetal oxygenation and risking hypoxia. This requires immediate reporting to the provider for interventions like position changes or oxygen administration to prevent fetal distress, making it the critical finding necessitating urgent action.

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A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse perform to assess the amount of drainage?

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