A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis?

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because when a baby's lips are flanged (turned out) while latched onto the breast, it indicates a proper latch and positioning for effective breastfeeding. This is crucial for optimal milk transfer and preventing nipple soreness or damage. Option B, feeding every 4 hours, is incorrect as newborns typically need to feed more frequently, usually every 2-3 hours, to establish a good milk supply and meet their nutritional needs. Option C, baby lost 12% of weight since birth, is concerning as it suggests inadequate milk intake or other underlying issues affecting feeding and growth, indicating ineffective breastfeeding rather than effective breastfeeding. Option D, baby's tongue stays behind the gum line, indicates a potential tongue-tie issue which can hinder proper latch and milk transfer, leading to ineffective breastfeeding. Educationally, understanding the signs of effective breastfeeding is crucial for nurses caring for postpartum mothers and newborns to provide appropriate support and interventions to ensure successful breastfeeding outcomes. Proper latch and positioning are fundamental for successful breastfeeding and promoting maternal-infant bonding. Identifying issues early and providing timely interventions can prevent breastfeeding challenges and promote a positive breastfeeding experience for the mother-newborn dyad.

Correct Answer: B

Rationale: The correct answer is B: Breastfeeding is protective for the baby and should be encouraged. This response is based on evidence-based practice and the benefits of breastfeeding for both the mother and the baby. Breastfeeding provides numerous health benefits, including boosting the baby's immune system and reducing the risk of certain infections and chronic diseases. Encouraging breastfeeding in this scenario is important to promote the well-being of the infant. Option A is incorrect because breastfeeding is not contraindicated if the mother smokes cigarettes. While smoking can have negative effects on breastfeeding, it is still possible for a mother to breastfeed while actively working on reducing or quitting smoking. Option C is incorrect as reporting a mother to child protective services for smoking would be extreme and inappropriate. Smoking, while harmful, does not constitute child abuse in this context. Option D is incorrect because admitting to smoking cigarettes does not automatically imply illicit substance abuse. It is essential to approach each situation with empathy and provide support and resources for smoking cessation rather than making assumptions about illicit substance abuse. In an educational context, it is crucial for healthcare professionals to be knowledgeable about the benefits of breastfeeding and how to support mothers in making informed choices regarding their infant's health. Understanding the impact of maternal behaviors, such as smoking, on breastfeeding can guide healthcare providers in offering appropriate guidance and support to promote the best outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In the context of postpartum hormonal changes and breastfeeding, the correct answer is option A) Place a pillow in her lap. This position helps support the baby's weight, allows the mother to relax her arms and shoulders, and promotes a comfortable latch for successful breastfeeding. Placing a pillow in her lap also helps maintain proper positioning and prevents strain on the mother's back and arms during feeding sessions. Option B) Position the head of the baby in her elbow is incorrect because it does not provide adequate support for the baby's body and head, leading to potential discomfort for both the mother and the baby. Option C) Put the baby on his back is incorrect as this position is not conducive to effective breastfeeding, as it does not allow for proper alignment of the baby's mouth to the breast. Option D) Move the breast toward the mouth of the baby is incorrect because the mother should bring the baby to the breast, not the breast to the baby, to ensure a proper latch and effective milk transfer. Educationally, it is crucial for new mothers to learn proper breastfeeding positions to establish a successful breastfeeding relationship with their newborn. By understanding and practicing correct positioning techniques, mothers can optimize milk flow, prevent nipple soreness, and promote bonding with their baby. Providing education on breastfeeding positions empowers mothers to feel confident and comfortable in nourishing their infants.

Correct Answer: A

Rationale: In the postpartum period, it is normal for newborns to lose some weight in the first few days of life. The correct action for the nurse in this scenario is option A) Nothing because this is an acceptable weight loss. Newborns typically lose up to 10% of their birth weight in the first week, and this neonate's weight loss of 100 grams falls within the expected range. Option B) advising the mother to supplement feedings with formula is not necessary at this point as the weight loss is within the normal range for a breastfeeding neonate. Option C) notifying the neonatologist of excessive weight loss is not warranted as the weight loss is not excessive. Option D) giving the baby dextrose water between breast feedings is not recommended as it may interfere with establishing successful breastfeeding and is unnecessary given the acceptable weight loss. Educationally, it is important for nurses to understand the normal physiological changes that occur in newborns postpartum to provide appropriate care and support to both the newborn and the mother. Monitoring weight loss, educating parents about normal newborn behaviors, and promoting breastfeeding are crucial aspects of postpartum care.

Correct Answer: D

Rationale: The correct response is option D: "Alcohol can be consumed at any time while you are breastfeeding." This option is correct because alcohol consumption during breastfeeding does not require complete abstinence, but rather careful timing and moderation. Option A is incorrect as it validates the mother's desire to consume alcohol, which can be harmful to her health and potentially impact the well-being of the baby. Option B is incorrect as it does not address the issue of alcohol consumption and its implications. Option C is incorrect because refraining from alcohol consumption is not necessary for the entire breastfeeding period but rather during specific times to ensure the safety of the baby. In an educational context, it is crucial for healthcare professionals to provide accurate information regarding postpartum care, including breastfeeding and alcohol consumption. Educating mothers on safe practices during breastfeeding is essential to promote the health and well-being of both the mother and the baby. It is important to emphasize the importance of moderation and timing when it comes to alcohol consumption while breastfeeding to ensure the baby's safety and optimal health outcomes.