A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum.
Which of the following information should the nurse include in the teaching?
Your baby's urine should appear dark and concentrated.
Your breasts should stay firm after the baby breastfeeds.
You should feel a tugging sensation when the baby is sucking.
You should expect your baby to have two to three wet diapers in a 24-hour period.
The Correct Answer is C
Choice A rationale
Dark and concentrated urine in an infant indicates inadequate hydration, which can be a sign of insufficient milk intake during breastfeeding. Well-hydrated infants, receiving adequate breast milk, typically produce urine that is pale yellow and dilute, not dark and concentrated. This reflects proper kidney function and fluid balance.
Choice B rationale
After effective breastfeeding, the breasts should feel softer and less engorged, not firm. The firmness before feeding is due to milk accumulation within the mammary glands. As the infant removes milk, the pressure decreases, leading to a softer breast texture, indicating successful milk transfer.
Choice C rationale
A tugging sensation during breastfeeding is a normal and expected physiological sign. This sensation results from the baby's effective latch and negative pressure creation, which draws milk from the milk ducts into the baby's mouth. It signifies proper milk ejection and efficient feeding.
Choice D rationale
Two to three wet diapers in a 24-hour period for a 5-day-old infant is indicative of insufficient fluid intake. A well-hydrated newborn at this age, receiving adequate breast milk, should typically have six to eight wet diapers per 24 hours, reflecting sufficient hydration and milk transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A prolonged period of absent FHR variability is a critical finding that the nurse must report to the provider immediately. Absent variability indicates a significant lack of fetal well-being, potentially due to severe hypoxia, acidosis, or neurological compromise. It necessitates prompt intervention to prevent adverse outcomes.
Choice B rationale
An FHR increase to 150/min is within the normal fetal heart rate range, which typically falls between 110 and 160 beats per minute. This finding alone does not indicate a problem and would not require reporting to the provider, as it suggests adequate fetal oxygenation and an appropriately reactive fetus.
Choice C rationale
FHR accelerations of 15/min for 15 seconds are a positive sign of fetal well-being. Accelerations indicate an intact fetal nervous system and adequate oxygenation. They are a reassuring finding and suggest that the fetus is tolerating the labor process well, therefore not requiring reporting.
Choice D rationale
Early decelerations of the FHR are typically benign and do not require reporting to the provider. These decelerations are usually associated with head compression during contractions and are characterized by a gradual decrease in FHR that mirrors the contraction, indicating a physiological response.
Correct Answer is D
Explanation
Choice A rationale
Depression is a common mental health condition and is not a contraindication for the use of a copper intrauterine device (IUD). The copper IUD is a non-hormonal contraceptive method, meaning it does not release hormones that could potentially interact with or exacerbate symptoms of depression. Therefore, it is a safe option for individuals with this condition.
Choice B rationale
Diabetes mellitus, when well-controlled, is not a contraindication for the use of a copper IUD. The copper IUD does not affect blood glucose levels or insulin sensitivity, making it a suitable contraceptive option for individuals with diabetes. Hormonal methods might require more careful consideration, but copper IUDs are generally safe.
Choice C rationale
Cholelithiasis, or gallstones, is a condition affecting the gallbladder and bile ducts. It is not a contraindication for the use of a copper IUD. The copper IUD's mechanism of action is local, primarily affecting the uterine environment, and does not involve systemic hormonal changes that would impact gallbladder function.
Choice D rationale
Dysmenorrhea, or painful menstruation, is a significant contraindication for the use of a copper IUD. The copper IUD is known to increase menstrual bleeding and cramping, which can worsen pre-existing dysmenorrhea. This potential exacerbation of symptoms can lead to client dissatisfaction and discontinuation of the method.
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