Level: Advanced
Difficulty: Hard
Subtopic: Breastfeeding support
NCLEX: A postpartum client on the mother-baby unit is being evaluated for breastfeeding initiation. Assessment data incl…
Maternal-newborn nursing Health Promotion and Maintenance Reduction of Risk Potential
Case Study
A postpartum client on the mother-baby unit is being evaluated for breastfeeding initiation. Assessment data include the newborn has a shallow latch and fewer wet diapers than expected. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that the newborn has a shallow latch and fewer wet diapers than expected.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that the newborn has a shallow latch and fewer wet diapers than expected.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.