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 A
Explanation
Choice A reason:
Panting can help prevent premature pushing and reduce the risk of cervical edema or laceration. The client should be instructed to take short, shallow breaths through her mouth during contractions until she reaches 10 cm of dilation.
Choice B reason:
Assessing the perineum for signs of crowning is not a priority at this stage, as the fetus is not yet at a low enough station to be visible. Crowning usually occurs when the fetus is at +4 or +5 station.
Choice C reason:
Assisting the client into a comfortable position is important, but it does not address the urge to push. The client should be encouraged to change positions frequently to promote fetal descent and comfort.
Choice D reason:
Helping the client to the bathroom to empty her bladder is not advisable, as it can increase the risk of cord prolapse or rupture of membranes. The client should have an indwelling catheter inserted if she is unable to void spontaneously.
Correct Answer is A
Explanation
Choice A reason: This is the most appropriate response because it reassures the client that the amount of lochia she passed is normal and expected after lying down for a long time. Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue. It usually decreases in amount and changes in color over time, from red to pink to brown to yellow.
Choice B reason: This is an incorrect response because it implies that the client has a complication that requires further evaluation. Retained placental fragments can cause excessive bleeding, infection, and uterine atony. The nurse should not alarm the client with this possibility without evidence.
Choice C reason: This is an incorrect response because it contradicts the normal patern of lochia. The amount of lochia usually decreases during the postpartum period, not increases. If the client has an increase in lochia, it could indicate a problem such as infection, subinvolution, or hemorrhage.
Choice D reason: This is an incorrect response because it confuses the client with unrelated information. Urinary tract infections are not associated with increased lochia. They are caused by bacteria entering the urinary tract and can cause symptoms such as dysuria, frequency, urgency, and hematuria. The nurse should not suggest that the client has a urinary tract infection without evidence.
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