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 documentation should the nurse record to best support safe care and communication?
Question
A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.