ATI RN NEW BORN 2016 A

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1. A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? ... A. Place warm, moist packs on the breasts. The client can use cold compresses to decrease breast discomfort during lactation suppression. B. Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. C. Wear a loose-fitting bra. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. D. Put green tea bags on the breasts. Tea bags are used to relieve nipple soreness in breastfeeding clients. 2. A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.) -Heart rate 154/min -Axillary temperature 36° C (96.8° F) -Respiratory rate 58/min -Length 43 cm (16.9 in) -Weight 2.6 kg (5 lb 12 oz) • A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. • An axillary temperature of 36° C (96.8° F) is incorrect. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). • A respiratory rate of 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. • A length of 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). • A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb). [Show More]

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