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
The lecithin/sphingomyelin (L/S) ratio test is a crucial assessment of fetal lung maturity. Lecithin and sphingomyelin are phospholipids that are components of surfactant, a substance vital for reducing surface tension in the alveoli and preventing lung collapse at birth. A ratio of 2: or greater generally indicates adequate lung maturity.
Choice B rationale
The L/S ratio test does not assess the baby's blood type. Fetal blood typing is determined through other methods, such as cordocentesis or maternal blood tests for fetal DNA, if clinically indicated. The L/S ratio specifically evaluates the quantity and ratio of pulmonary surfactants.
Choice C rationale
This test does not check the baby's liver development. Fetal liver development is assessed through different parameters, such as ultrasound visualization of liver size, blood flow characteristics, and specific liver enzyme levels if a concern exists. The L/S ratio is solely focused on pulmonary maturity.
Choice D rationale
The L/S ratio test is not used to check for genetic disorders. Genetic disorders are identified through chromosomal analysis, DNA sequencing, or biochemical tests performed on amniotic fluid cells obtained during amniocentesis, or through chorionic villus sampling. The L/S ratio is a physiological marker of lung readiness.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.
Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.
Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.
Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.
Take home points
- Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
- Abnormal muscle tone and tremors are key signs of potential neurological complications.
- Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
- Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.
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