The nurse has reviewed the Nurses' Notes and Diagnostic Results from 9 weeks ago.

The nurse is providing discharge teaching to the client and their support person.
For each potential client instruction, click to specify if the client instruction is expected or unexpected for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A. Breastfeeding should not be strictly time-limited. Newborns need to feed based on their own hunger and satiety cues, and feeding duration varies widely (often 10–20+ minutes per breast). Limiting time can interfere with adequate intake of both foremilk and hindmilk, potentially affecting nutrition and growth.

B. It is recommended to alternate the starting breast with each feeding. Beginning with the same breast consistently can lead to engorgement on one side and may reduce stimulation and milk production in the other breast. Alternating ensures balanced milk production and comfort.

C. Breastfed infants do not require water supplementation, even in most warm climates, because breast milk provides adequate hydration. Giving water can interfere with feeding frequency, reduce caloric intake, and potentially lead to water intoxication or electrolyte imbalance in infants.

D. This reflects cue-based or demand feeding, which is the recommended approach for breastfeeding. Early hunger cues include rooting, sucking on hands, lip smacking, and increased alertness. Feeding on demand supports adequate milk supply, promotes infant growth, and improves breastfeeding success and bonding.

Rationale:

A. A mildly elevated temperature may indicate infection or inflammation, which is important in sickle cell disease, but it is not a defining or immediate indicator of acute chest syndrome. Acute chest syndrome typically presents with more severe respiratory compromise along with fever ≥ 38.5°C (101.3°F) or higher in many cases.

B. Acute chest syndrome is characterized by respiratory distress such as tachypnea, hypoxia, and increased work of breathing. Bradypnea (slow respiratory rate) is not typical and would be more concerning for central nervous system depression or late-stage respiratory failure rather than early acute chest syndrome.

C. Sneezing is associated with upper respiratory irritation or allergic rhinitis and is not related to acute chest syndrome. Acute chest syndrome involves the lungs and is typically caused by infection, fat embolism, or vaso-occlusion leading to pulmonary complications.

D. Substernal retractions indicate increased work of breathing and respiratory distress. In a client with sickle cell disease, this is a serious finding that may indicate acute chest syndrome, which is a medical emergency characterized by chest pain, hypoxia, fever, cough, and respiratory compromise.