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 D
Explanation
Choice A reason:
Given too soon, epidural anesthesia can cause fetal depression is incorrect, as epidural anesthesia does not cross the placenta and does not affect the fetal status.
Choice B reason:
Given too soon, epidural anesthesia will delay rupture of fetal membranes is incorrect, as epidural anesthesia does not interfere with the rupture of membranes. The rupture of membranes depends on the cervical dilation and effacement, the position of the presenting part, and the strength of contractions.
Choice C reason:
Given too soon, epidural anesthesia can cause maternal hypertension is incorrect, as epidural anesthesia can cause maternal hypotension due to vasodilation and decreased venous return. The nurse should monitor the client's blood pressure and administer fluids and vasopressors as needed.
Choice D reason:
Given too soon, epidural anesthesia can prolong labor is correct, as epidural anesthesia can decrease the strength and frequency of contractions and reduce the urge to push. The nurse should ensure that the client has a good labor patern before administering epidural anesthesia and monitor the progress of labor afterwards.
Correct Answer is B
Explanation
Choice A reason: Request the RN perform a cervical examination is incorrect, as this action is not indicated for a client who has a history of genital herpes. A cervical examination can introduce infection and trauma to the cervix and increase the risk of viral shedding and transmission to the fetus. The nurse should avoid performing or requesting a cervical examination unless absolutely necessary.
Choice B reason: Initiate fetal monitoring for baseline and changes is correct, as this action is appropriate for any client who is in labor. Fetal monitoring can provide information about the fetal heart rate, variability, accelerations, decelerations, and contractions. The nurse should monitor the fetal status continuously and report any abnormal findings to the provider.
Choice C reason: Prepare for a vaginal birth is incorrect, as this action may not be possible for a client who has a history of genital herpes. A vaginal birth can expose the fetus to the herpes virus and cause neonatal infection, which can be life-threatening. The nurse should assess the client for signs of active lesions or prodromal symptoms and prepare for a cesarean birth if indicated.
Choice D reason: Administer antibiotics is incorrect, as this action is not effective for a client who has a history of genital herpes. Genital herpes is caused by a virus, not a bacteria, and antibiotics have no effect on viral infections. The nurse should administer antiviral medications as prescribed to reduce viral shedding and transmission to the fetus.
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