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 A

Explanation

Choice A reason: A precipitous birth is a delivery that occurs in less than 3 hours from the onset of labor. This can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after the placenta is delivered. Uterine atony is the most common cause of postpartum hemorrhage²³.

Choice B reason: A small for gestational age newborn is not a risk factor for postpartum hemorrhage. It may be associated with other conditions, such as placental insufficiency or intrauterine growth restriction, but these do not directly increase the risk of bleeding after delivery.

Choice C reason: A two-vessel umbilical cord is a cord that has one artery and one vein instead of the normal two arteries and one vein. This can be a marker for congenital anomalies or placental abnormalities, but it does not increase the risk of postpartum hemorrhage by itself.

Choice D reason: Gestational hypertension is a condition where the blood pressure rises above 140/90 mm Hg after 20 weeks of pregnancy. It can lead to complications such as preeclampsia, eclampsia, or HELLP syndrome, which can aﬀect the clotting system and cause bleeding disorders. However, gestational hypertension alone does not increase the risk of postpartum hemorrhage unless it is associated with these severe conditions¹⁴.

A. Feel for a full bladder. B. Check the client's fundus. C. Measure the client's vital signs. D. Request the provider perform a vaginal examination.

Correct Answer is B

Explanation

Choice A reason:
Feeling for a full bladder is not the first action the nurse should take, although it is important to assess for bladder distension and urinary retention in postpartum clients. A full bladder can displace the uterus and increase the risk of uterine atony and hemorrhage.

Choice B reason:
Checking the client's fundus is the first action the nurse should take, as it can indicate the tone and position of the uterus. A firm and midline fundus indicates adequate uterine contraction and prevents excessive bleeding. A boggy or deviated fundus indicates uterine atony or retained placental fragments, which can cause hemorrhage.

Choice C reason:
Measuring the client's vital signs is not the first action the nurse should take, although it is important to monitor for signs of shock and infection in postpartum clients. Vital signs can be aﬀected by various factors and do not provide a direct assessment of uterine status.

Choice D reason:
Requesting the provider perform a vaginal examination is not the first action the nurse should take, as it can introduce infection and trauma to the perineum. A vaginal examination is only indicated if there is suspicion of cervical or vaginal lacerations or retained placenta.

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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 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?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV ﬂuids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes breasts soft, fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

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A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

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?