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 D

No explanation

A. Collect 2 mL of sputum in an emesis basin B. Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection. C. Swab the oropharynx with a sterile swab D. Refrigerate the specimen until the time of transport to the laboratory

Correct Answer is D

Explanation

Answer: D

Rationale:

A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.

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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

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Explanation

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