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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Wear a nipple shield is incorrect, as this recommendation is not indicated for a client who has engorged breasts. A nipple shield is a thin, flexible device that covers the nipple and areola and can help with latch problems, flat or inverted nipples, or sore nipples. However, a nipple shield can also reduce milk transfer, stimulate less milk production, and cause nipple confusion or preference.
Choice B reason: Express milk from both breasts is correct, as this recommendation can help relieve engorgement and maintain milk production. Engorgement is a normal and expected phenomenon that occurs when the milk comes in, usually around 72 to 96 hr after birth. Engorgement can cause breast fullness, tenderness, warmth, and hardness. The nurse should advise the client to express milk from both breasts by breastfeeding frequently and effectively or by using a breast pump or hand expression.
Choice C reason: Obtain a prescription for an antibiotic is incorrect, as this recommendation is not indicated for a client who has engorged breasts. An antibiotic is used to treat mastitis, which is an infection and inflammation of the breast tissue that can cause redness, pain, swelling, warmth, and fever in the affected breast. The nurse should assess the client for signs of mastitis and report any abnormal findings to the provider.
Choice D reason: Apply a heating pad to her breasts is incorrect, as this recommendation can worsen engorgement and cause discomfort. A heating pad can increase blood flow and swelling in the breasts, which can impair milk flow and increase pain. The nurse should advise the client to apply cold compresses or cabbage leaves to her breasts to reduce inflammation and discomfort.
Correct Answer is B
Explanation
Choice B reason:
A fundus that is elevated and displaced from the midline indicates a full bladder, which can interfere with uterine contraction and increase the risk of hemorrhage. The nurse should assist the client to void or catheterize her if necessary.
Choice A reason:
Moderate swelling of the labia is a normal finding after vaginal delivery, and does not indicate a need to urinate. The nurse should apply ice packs and perineal pads to reduce edema and discomfort.
Choice C reason:
Moderate lochia rubra is a normal finding during the first 24 hr postpartum, and does not indicate a need to urinate. The nurse should monitor the amount and color of lochia, and change the perineal pads as needed.
Choice D reason:
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum client, and does not indicate a need to urinate. The nurse should monitor the blood pressure for signs of hypertension or hypotension, which can indicate complications such as preeclampsia or hemorrhage.
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