A nurse is providing care for a postpartum client.

The client’s medical history includes Gravida 1, Para 1, and a spontaneous vaginal birth. The nurse’s notes indicate that the client is at 39 weeks of gestation and is breastfeeding.

Which of the following statements made by the client would suggest that they have understood the discharge instructions?
Which of the following statements made by the client would suggest that they have understood the discharge instructions?

“I should ensure that my baby feeds 8 to 12 times per day.”.

“Given my baby’s weight loss, I need to supplement with formula after breastfeeding.”.

“I should protect my sore nipples with plastic-lined breast pads after each feeding.”.

“I can boost my milk supply by drinking more water.”. .

Answer and Explanation

The Correct Answer is A

Choice A rationale

This statement is correct. It is recommended that newborns be breastfed 8 to 12 times per day, which is about every 2 to 3 hours.

Choice B rationale

Supplementing with formula after breastfeeding is not typically recommended unless there is a medical reason. Supplementing can interfere with the supply and demand process that increases milk supply.

Choice C rationale

Using plastic-lined breast pads can trap moisture and exacerbate sore nipples. It is recommended to use 100% cotton breast pads and to change them frequently to keep the nipples dry.

Choice D rationale

While staying hydrated is important for overall health, there is no definitive evidence that drinking more water will increase milk supply. However, some mothers find that staying well- hydrated helps with their overall comfort and well-being during breastfeeding.

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Correct Answer is D

Explanation

The correct answer is choiced. Slightly above the umbilicus.

Choice A rationale:

At 22 weeks of gestation, the fundus is not typically 5 cm above the umbilicus. This measurement would be more consistent with a later stage of pregnancy, around 28 weeks.

Choice B rationale:

The fundus being slightly below the umbilicus is more consistent with an earlier stage of pregnancy, around 20 weeks. At 22 weeks, the fundus should be higher.

Choice C rationale:

The fundus being 3 cm below the umbilicus is also indicative of an earlier stage of pregnancy, not 22 weeks. This would be expected around 18-20 weeks.

Choice D rationale:

At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus.This corresponds with the general rule that the fundal height in centimeters should match the number of weeks of pregnancy, give or take 2 cm.

A. Administer Vitamin K B. Administer eye prophylaxis C. Place an identification bracelet D. Dry the skin

Correct Answer is D

Explanation

Choice A rationale

Administering Vitamin K is an important step in newborn care as it helps with blood clotting and prevents a rare but serious bleeding disorder called Vitamin K Deficiency Bleeding.

However, it is not the immediate priority after ensuring a patent airway.

Choice B rationale

Administering eye prophylaxis, typically in the form of antibiotic ointment, is a standard procedure in newborn care to prevent neonatal conjunctivitis. However, this is not the immediate priority after ensuring a patent airway.

Choice C rationale

Placing an identification bracelet on the newborn is crucial for ensuring the baby’s safety and preventing mix-ups. However, this is not the immediate priority after ensuring a patent airway.

Choice D rationale

Drying the skin of the newborn is the priority action after ensuring a patent airway. This is because newborns are wet with amniotic fluid at birth, and they can lose heat quickly through evaporation if not dried immediately. This can lead to hypothermia, which can be dangerous for the newborn.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is D

Explanation

A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse’s priority action?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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