A nurse is reinforcing discharge instructions with a postpartum client about breastfeeding.
Which of the following statements by the client indicates an understanding of the teaching?
I will increase my potassium intake while breastfeeding.
I will maintain adequate fluid intake to quench my thirst.
I will maintain the same caloric intake as during pregnancy.
I will increase my intake of vitamin
The Correct Answer is B
Choice A rationale
While potassium is essential, there is typically no specific recommendation to increase intake beyond general healthy eating during breastfeeding. The focus is on adequate intake of fluids, calories, and certain nutrients like protein, calcium, iron, and Vitamin D. The recommended daily potassium intake for lactating women is 2,800 mg.
Choice B rationale
Maintaining adequate fluid intake to quench thirst is a critical and accurate instruction. Milk is primarily composed of water, so the process of lactation increases the mother's fluid requirements to maintain hydration and support consistent milk production, preventing dehydration, which is typically regulated by responding to the sensation of thirst.
Choice C rationale
Caloric needs during exclusive breastfeeding increase compared to pregnancy, typically by about 330 to 400 extra calories per day above pre-pregnancy needs, due to the energy demands of synthesizing milk. Maintaining the same caloric intake as during pregnancy will likely lead to an energy deficit, potentially compromising maternal reserves or milk supply.
Choice D rationale
While Vitamin K is essential for blood clotting, there is no specific instruction to increase its intake above the Recommended Dietary Allowance (RDA), which is 90 mcg/day for lactating women, as it's widely available in a balanced diet. The primary concern is often Vitamin D and calcium, not a significant increase in Vitamin K.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying vitamin E oil to the nipples is not generally recommended; it offers little benefit and could potentially introduce unnecessary substances to the infant during feeding. Lanolin cream or purified lanolin is often recommended for sore nipples because it provides moisture, promotes healing by creating a barrier, and is safe for the baby to ingest. Proper latch technique is the primary intervention for preventing nipple soreness.
Choice B rationale
Limiting feeding time to 5 to 10 minutes per breast is incorrect and can lead to inadequate milk intake and insufficient stimulation for milk production. The infant should be allowed to feed for as long as they actively suckle and swallow, usually 15 to 20 minutes or until the breast feels softer, ensuring they receive the higher-calorie hindmilk.
Choice C rationale
Positioning the baby on a pillow at the level of the breast promotes a more comfortable and effective latch. Proper positioning allows the infant's mouth to be level with the nipple, ensuring the baby can take in a large portion of the areola and preventing strain on the mother's back, which facilitates a deeper and more comfortable latch for effective milk transfer.
Choice D rationale
Ensuring just the nipple is in the baby's mouth is an incorrect technique and is a common cause of nipple soreness and inadequate milk transfer. The baby needs to take in a large portion of the areola to effectively compress the milk sinuses underneath, achieving a deep latch that stimulates milk release and minimizes nipple trauma.
Correct Answer is B
Explanation
Choice A rationale
The Babinski reflex is a primitive neurological reflex tested by stroking the sole of the foot. A normal response in a newborn is fanning of the toes, which indicates an intact central nervous system. This reflex, though important for neurological assessment, does not provide immediate data for evaluating respiratory or muscle tone complications, which are assessed by other parameters.
Choice B rationale
Heart rate is a critical component of the Apgar score, along with muscle tone, reflex irritability, color, and respiration. A low or declining heart rate (normal range 120-160 beats/min in a newborn) is often an early and sensitive indicator of hypoxia, circulatory compromise, or significant physiological distress, making it essential for immediate complication assessment.
Choice C rationale
The Moro reflex (startle reflex) is a primitive reflex observed by a sudden change in position. Its presence indicates neurological integrity. While its absence could signal a neurological or musculoskeletal injury, it is not an immediate parameter used for rapid assessment of cardiorespiratory stability in a distressed newborn like heart rate or blood glucose.
Choice D rationale
Blood glucose (normal 40-60 mg/dL) is important for energy homeostasis, and hypoglycemia can lead to lethargy, hypotonia, and respiratory distress. However, it is not as rapid or direct a measure of immediate oxygenation and perfusion status as the heart rate and respiratory effort are for determining acute complications.
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