A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?
"Babies know instinctively exactly how much of the nipple to take into their mouth."
"Your baby's mouth is rather small so she will only take part of the nipple."
"Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth."
"You should place your nipple and some of the areola into her mouth."
The Correct Answer is D
Choice A reason: "Babies know instinctively exactly how much of the nipple to take into their mouth." is incorrect, as this response does not provide adequate guidance or support for the client. Babies may not always latch on correctly or effectively, especially in the first few atempts. The nurse should teach the client how to position and latch the baby properly and observe for signs of effective breastfeeding.
Choice B reason: "Your baby's mouth is rather small so she will only take part of the nipple." is incorrect, as this response can lead to ineffective breastfeeding and nipple trauma. Taking only part of the nipple can cause poor milk transfer, inadequate milk production, and nipple soreness or cracking. The nurse should teach the client how to ensure that the baby takes enough of the nipple and areola into their mouth.
Choice C reason: "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth." -Including too much breast tissue can be uncomfortable. While some areola is important, including too much breast tissue can hinder proper latch and milk flow.
Choice D reason: "You should place your nipple and some of the areola into her mouth." This accurately describes the ideal latch for breastfeeding. Including some of the areola helps the baby latch deeply and comfortably, promoting milk transfer and preventing feeding difficulties and nipple soreness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "You will experience urinary retention." is incorrect, as this statement does not describe a sign preceding the onset of labor. Urinary retention can occur during labor due to pressure from the fetal head or epidural anesthesia, but it is not a sign that labor is imminent. The nurse should encourage the client to void frequently and monitor their bladder status.
Choice B reason: "You will have a decrease in vaginal discharge." is incorrect, as this statement does not describe a sign preceding the onset of labor. Vaginal discharge can increase before labor due to cervical ripening and dilation, which can cause bloody show or mucus plug loss. The nurse should educate the client about normal and abnormal vaginal discharge and when to report it.
Choice C reason: "You will experience a surge of energy." is correct, as this statement describes a sign preceding the onset of labor. A surge of energy, also known as nesting instinct, can occur before labor due to hormonal changes or psychological factors. The nurse should advise the client to conserve their energy and rest as much as possible before labor.
Choice D reason: "You will have a weight gain of 0.5 to 1.5 kilograms." is incorrect, as this statement does not describe a sign preceding the onset of labor. Weight gain can occur during pregnancy due to fetal growth, fluid retention, or increased caloric intake, but it is not a sign that labor is imminent. The nurse should monitor the client's weight and fluid balance and report any sudden or excessive weight gain that may indicate preeclampsia or other complications.
Correct Answer is B
Explanation
Choice A reason:
A warm sitz bath can promote healing and comfort, but it is not recommended until 24 hr after delivery, as it can increase swelling and bleeding.
Choice B reason:
An ice pack can reduce inflammation and pain by causing vasoconstriction and numbing the area. It should be applied for 20 minutes at a time, with a cloth barrier between the skin and the ice.
Choice C reason:
A soft pillow under the client's butocks can increase pressure on the perineum and worsen the pain. The client should be encouraged to lie on her side or sit in a semi-Fowler's position.
Choice D reason:
A heating lamp can dry out the wound and delay healing. It can also cause burns and discomfort. It should be avoided for episiotomy care.
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