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. Before teaching, what should the nurse assess first?
Question
A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.