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 A
Explanation
Choice A reason: Position the client on her side is correct, as this is the first action the nurse should take according to the ABCDE priority framework. Late decelerations are symmetrical decreases in the fetal heart rate that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency and fetal hypoxia. Positioning the client on her side can improve blood flow and oxygen delivery to the placenta and fetus by relieving pressure on the vena cava and aorta.
Choice B reason: Elevate the client's legs is incorrect, as this is not a priority action for a client who has late decelerations. Elevating the legs can increase venous return and cardiac output, but it can also reduce blood flow and oxygen delivery to the placenta and fetus by compressing the vena cava and aorta.
Choice C reason: Administer oxygen via face mask is incorrect, as this is not the first action the nurse should take, although it is important to do later. Administering oxygen can increase oxygen saturation and delivery to the placenta and fetus, but it does not address the cause of uteroplacental insufficiency or improve blood flow.
Choice D reason: Increase the infusion rate of the IV fluid is incorrect, as this is not the first action the nurse should take, although it may be indicated later. Increasing the infusion rate of IV fluid can expand blood volume and improve placental perfusion, but it does not address the cause of uteroplacental insufficiency or improve blood flow. The nurse should obtain a provider's order before increasing the IV fluid rate.
Correct Answer is A
Explanation
Choice A reason: The client is Rh negative and the newborn is Rh positive is correct, as this finding indicates a risk of Rh incompatibility and sensitization. Rh incompatibility occurs when the mother has Rh-negative blood and the baby has Rh-positive blood, which can cause maternal antibodies to atack the fetal red blood cells. Sensitization occurs when the maternal antibodies cross the placenta and enter the fetal circulation, which can cause hemolytic disease of the newborn. The nurse should administer Rho(D) immune globulin to prevent sensitization and protect future pregnancies.
Choice B reason: The client is Rh negative and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Choice C reason: The client is Rh positive and the newborn is Rh positive is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If both the mother and the baby have Rh-positive blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
Choice D reason: The client is Rh positive and the newborn is Rh negative is incorrect, as this finding does not indicate a risk of Rh incompatibility or sensitization. If the mother has Rh-positive blood and the baby has Rh- negative blood, there is no antigen-antibody reaction and no need for Rho(D) immune globulin.
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