Health Promotion and Maintenance
77. A nurse enters the room of a client who is a 22-year-old primigravida who was 39 weeks' gestation. The infant was delivered using vacuum extraction 3 hours ago. The client is in tears and says "When I first delivered, the baby breastfed for almost an hour, now the baby won't wake up enough to take the nipple!" Which intervention would be most appropriate in this case?
. Instruct the client to supplement breastfeeding with formula; the baby isn't waking up because there isn't enough milk.
. Instruct the client to wake the baby by changing the baby's diaper.
. Instruct the client to let the baby sleep, because babies cluster-feed, and frequently sleep for several hours after the initial breastfeeding.
. Instruct the client to submerge the baby into a bath of lukewarm water to wake the baby up so that the baby will breastfeed.
Test-Taking Tip
Is this a normal newborn infant behavior? Or, is this a problem? Remember that normal newborn infants are demand-fed and the normal feeding pattern is cluster feeding 8 to 12 times in a 24-hour period. The infant's initial alertness and eagerness are followed by an increasingly deeper sleep. At about 20 to 24 hours of age, the baby will be awake more often and be more interested in nursing. Eliminate the two options that call for waking the baby who is in a normal sleep state (Answers 2 and 4).
Content Area: Maternity, Postpartum; Integrated Process: Teaching and Learning; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because this infant's initial alertness and eagerness are followed by an increasingly deeper sleep. This infant is only 3 hours old, and the client should be instructed to wait for the infant to wake up. At about 20 to 24 hours of age, the baby will be awake more often and be more interested in nursing. Answer 2 is incorrect because this infant is in a normal sleep state and does not need to be awakened for a feeding. Answer 3 is correct because the infant's suckling reflex is greatest from 45 minutes to 2 hours after birth. The baby may nurse several times close together (cluster feedings) and then sleep several hours without nursing. Answer 4 is incorrect because this infant is in a normal sleep state and does not need to be awakened for a feeding. In addition, the client should be instructed to sponge bathe, not submerse, the infant until the cord falls off.