A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast.
The nurse determines that the client's nipples are inverted. Which action should the nurse implement?
Encourage the use of ice on the areola.
Teach about the use of a breast pump.
Offer supplemental formula feedings.
Recommend using a breast shield.
The Correct Answer is B
The correct answer is Choice B.
Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.
Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.
Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.
Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
Explanation
Course breath sounds - Respiratory Distress
Decreased level of consciousness - Cerebral Edema
Seizure activity - Cerebral Edema
Irritability - Both (Can be associated with both cerebral edema and respiratory distress)
Bradycardia - Cerebral Edema
Rationale:
Course breath sounds - Respiratory Distress
Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.
Decreased level of consciousness - Cerebral Edema
A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.
Seizure activity - Cerebral Edema
Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.
Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.
Bradycardia - Cerebral Edema
Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
