Which of the following information should the nurse include in the teaching about effective breastfeeding for a client who is 5 days postpartum?
Your baby's urine should appear dark and concentrated.
You should expect your baby to have two to three wet diapers in a 24-hour period.
You should feel a tugging sensation when the baby is sucking.
Your breasts should stay firm after the baby breastfeeds.
The Correct Answer is C
Choice A reason: Dark, concentrated urine in a 5-day-old newborn indicates inadequate milk intake, as effective breastfeeding produces pale, dilute urine due to sufficient hydration. Breast milk provides water and nutrients, supporting renal function and urine output. This finding suggests dehydration, requiring intervention to ensure adequate feeding and prevent neonatal metabolic complications.
Choice B reason: Expecting only two to three wet diapers in 24 hours is inadequate for a 5-day-old breastfed newborn. Effective breastfeeding results in six to eight wet diapers daily, reflecting sufficient milk intake and hydration. Low diaper counts indicate poor feeding, risking dehydration and weight loss, which does not align with successful breastfeeding physiology.
Choice C reason: A tugging sensation during breastfeeding indicates effective latch and suckling, ensuring milk transfer. This sensation reflects the infant’s strong suck, stimulating milk ejection via oxytocin release. Proper latch promotes adequate nutrition and hydration, supporting neonatal growth and preventing dehydration, aligning with the physiological mechanics of successful breastfeeding.
Choice D reason: Breasts staying firm after breastfeeding suggests incomplete milk transfer, indicating ineffective feeding. Effective breastfeeding softens breasts due to milk removal, stimulated by infant suckling and oxytocin-mediated letdown. Firm breasts may signal poor latch or insufficient feeding frequency, risking engorgement or reduced milk supply, contrary to successful breastfeeding outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A change in deep tendon reflexes from 4+ (hyperreflexic) to 2+ (normal) indicates magnesium sulfate’s therapeutic effect in preeclampsia, as it reduces neuronal excitability, preventing seizures. Magnesium stabilizes nerve membranes, lowering seizure risk by modulating calcium channels, aligning with its anticonvulsant role in preeclampsia management.
Choice B reason: A fetal heart rate increase from 150/min to 166/min is not a direct indicator of magnesium sulfate’s effectiveness. Magnesium primarily prevents maternal seizures, not fetal heart rate changes. This increase may reflect fetal stress or normal variation, unrelated to magnesium’s neurological stabilization in preeclampsia treatment.
Choice C reason: Minimal fetal heart rate variability suggests fetal compromise, not magnesium sulfate’s desired effect. Magnesium aims to prevent maternal seizures without significantly altering fetal heart patterns. Reduced variability may indicate hypoxia, requiring separate intervention, as it does not reflect the drug’s therapeutic goal of maternal neurological stabilization.
Choice D reason: Urinary output of 20 mL/hr indicates potential magnesium toxicity or renal impairment, not therapeutic effectiveness. Magnesium sulfate requires adequate renal excretion to avoid toxicity, and output below 30 mL/hr suggests accumulation, risking respiratory depression or cardiac effects, contrary to the drug’s intended anticonvulsant action in preeclampsia.
Correct Answer is D
Explanation
Choice A reason: Palpation of the fetal presenting part in the cervical os indicates labor progression or malpresentation, not uterine rupture. Uterine rupture involves uterine wall tearing, causing hemorrhage or fetal extrusion, not cervical findings. This finding is unrelated to the catastrophic internal bleeding or placental disruption characteristic of rupture.
Choice B reason: Severe bradypnea (respiratory rate of 10/min) is not a primary sign of uterine rupture. Rupture causes hemorrhage, leading to hypovolemic shock with symptoms like hypotension or tachycardia. Respiratory changes may occur secondary to shock but are not specific. Uterine rupture primarily affects cardiovascular stability, not respiratory rate.
Choice C reason: A sudden gush of amniotic fluid indicates membrane rupture, a normal labor event, not uterine rupture. Uterine rupture involves uterine wall tearing, causing bleeding or fetal distress, not fluid release. Amniotic fluid loss is unrelated to the structural failure or hemorrhagic shock associated with uterine rupture in VBAC.
Choice D reason: Hypotension (85/40 mm Hg) indicates uterine rupture, as it suggests hypovolemic shock from internal hemorrhage due to uterine wall tearing. Blood loss reduces intravascular volume, impairing cardiac output and placental perfusion. This life-threatening sign in VBAC requires immediate intervention to address maternal and fetal compromise, aligning with rupture’s pathophysiology.
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