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.

Answer and Explanation

The Correct Answer is D

A)   Incorrect - Encouraging the use of ice on the areola is not a recommended intervention for addressing inverted nipples and promoting successful breastfeeding.
B)   Incorrect - Teaching about the use of a breast pump might be useful for milk expression but may not directly address the issue of latching due to inverted nipples.
C)   Incorrect - Offering supplemental formula feedings does not address the underlying issue of inverted nipples and breastfeeding difficulties.
D)   Correct-inverted nipples can make breastfeeding challenging as the baby may have difficulty latching directly onto the breast. A breast shield can be recommended to help draw out the nipple and create a more optimal shape for latching. It can also provide a larger surface area for the baby to grasp onto, making breastfeeding more successful for both the mother and the baby.

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Correct Answer is C

Explanation

Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.

Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.

Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence.

Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.

Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management

A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Observe both lower extremities for redness and swelling. D. Evaluate the client's ability to use an incentive spirometer.

Correct Answer is C

Explanation

The correct answer is choice C. Observe both lower extremities for redness and swelling.

Choice A rationale:

Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.

Choice B rationale:

Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.

Choice C rationale:

Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.

Choice D rationale:

Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is C

Explanation

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Correct Answer is C

Explanation

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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?