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.

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Correct Answer is ["C","D","E"]

Explanation

Choice A reason: While ice packs can help reduce swelling and discomfort, they are not essential for preventing infection.

Choice B reason: Sit on an inﬂatable donut to protect the perineum is incorrect, as this can increase pressure and blood ﬂow to the perineum and delay healing. The nurse should advise the client to avoid sitting on hard or uneven surfaces and to use a pillow or a cushion for comfort.

Choice C reason: Perform hand hygiene before and after voiding is correct, as this can prevent contamination and infection of the perineal area. The nurse should instruct the client to wash their hands with soap and water or use an alcohol-based hand sanitizer before and after using the toilet.

Choice D reason: Blot the perineal area dry after voiding is correct, as this can keep the perineal area clean and dry and prevent irritation and infection. The nurse should instruct the client to use a clean, soft cloth or tissue and gently pat or blot the perineal area from front to back after voiding.

Choice E reason: Clean the perineal area from front to back is correct, as this can prevent bacteria from entering the vagina or urethra and causing infection. The nurse should instruct the client to use a peri-botle filled with warm water and squirt it over the perineal area from front to back after each voiding or bowel movement. The client should also change their perineal pad frequently and dispose of it properly.

A. Prepare a warm sitz bath. B. Apply an ice pack to the perineum. C. Place a soft pillow under the client's butocks. D. Position a heating lamp toward the episiotomy.

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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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 reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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?

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 postpartum client who saturates a perineal pad in 10 min. Which of the following actions should the nurse take first?

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

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 collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

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?