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."

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Fundal consistency is correct, as this finding can indicate the eﬀectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.

Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not aﬀected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.

Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of shock or infection.

Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Urinary output can indicate the client's renal function and ﬂuid balance, but it can be inﬂuenced by many other factors, such as ﬂuid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.

Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of hypotension or hypertension.

A. The client is Rh negative and the newborn is Rh positive. B. The client is Rh negative and the newborn is Rh negative. C. The client is Rh positive and the newborn is Rh positive. D. The client is Rh positive and the newborn is Rh negative.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

A nurse is caring for a client who is 12 hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take?

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?