A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding eﬀectively?

Falls asleep 5 minutes after starting a feeding

Has 3 wet diapers each day.

Has a bowel movement every other day.

Makes audible swallowing sounds.

Answer and Explanation

The Correct Answer is D

The nurse should identify that the newborn is making audible swallowing sounds as an indication that they are breastfeeding eﬀectively. This indicates that the newborn is able to latch onto the breast and transfer milk eﬀectively.

a) Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not getting enough milk.

b) Having 3 wet diapers each day is not enough for a 5-day-old newborn. A newborn should have at least 6 wet diapers per day.

c) Having a bowel movement every other day is not an indication of eﬀective breastfeeding. A breastfed newborn should have at least 3 bowel movements per day.

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Correct Answer is C

Explanation

Answer: C. Weigh the client each morning after voiding

Rationale:

A. Encourage the client to gain 2.3 kg (5 lb) per week:
A weight gain goal of 0.5 to 1 kg (1 to 2 lb) per week is considered safe and realistic. Gaining 2.3 kg (5 lb) weekly is too aggressive and may cause physical and psychological stress for the client.

B. Monitor the client for 15 min after meals:
Clients with anorexia nervosa are at risk for purging behaviors. Monitoring for only 15 minutes is insufficient. A 60-minute post-meal observation period is more appropriate to deter vomiting or excessive exercise.

C. Weigh the client each morning after voiding:
Daily weights, taken at the same time each morning after voiding and before eating, provide consistent and accurate data to monitor progress and detect manipulation or fluid shifts.

D. Reinforce teaching about healthy eating during meals:
Reinforcing education during meals can increase the client’s anxiety and resistance to eating. Teaching is best done separately from mealtimes to avoid associating eating with stress.

A. Administer a reversal agent B. Initiate cardiac monitoring C. Instruct the client to stand up slowly. D. Inform the client to report urinary retention

Correct Answer is C

Explanation

c. Instruct the client to stand up slowly.

Explanation:

The correct answer is c. Instruct the client to stand up slowly.

Prazosin is an alpha-1 adrenergic blocker used to treat hypertension and benign prostatic hyperplasia. One of the common side eﬀects of prazosin is orthostatic hypotension, which can cause a drop in blood pressure when changing positions from lying or sitting to standing.

In this scenario, the client's blood pressure is 100/60 mm Hg, which indicates hypotension. To prevent a sudden drop in blood pressure and related symptoms such as dizziness or fainting, the nurse should instruct the client to stand up slowly. This allows the body time to adjust to the change in position and minimizes the risk of orthostatic hypotension.

Option a, administering a reversal agent, is not necessary in this situation. Reversal agents are used to counteract the eﬀects of specific medications when there is a need to rapidly reverse their actions. There is no indication in the scenario that the client requires a reversal agent.

Option b, initiating cardiac monitoring, is not warranted based solely on a blood pressure reading of 100/60 mm Hg. Cardiac monitoring is typically indicated when there are specific cardiac concerns or symptoms, which are not mentioned in the scenario.

Option d, informing the client to report urinary retention, is a potential side eﬀect of prazosin but is not the most appropriate action to take in this situation. The client's blood pressure is the immediate concern, and addressing orthostatic hypotension by instructing the client to stand up slowly is the appropriate action.

By instructing the client to stand up slowly, the nurse promotes safety and minimizes the risk of orthostatic hypotension, allowing the client to adjust to the change in position and reduce the likelihood of experiencing symptoms related to low blood pressure.

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A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding eﬀectively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with planning care for a newly admited client who has anorexia nervosa. Which of the following interventions should the nurse recommend to include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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