A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
Have the client limit the length of breastfeeding to 5 min per breast.
Instruct the client to wait 4 hr between daytime feedings.
Offer supplemental formula between the newborn's feedings.
Assess the newborn's latch while breastfeeding.
The Correct Answer is D
Rationale:
A. Limiting the length of breastfeeding to 5 minutes per breast is not recommended and may lead to inadequate milk transfer and supply issues.
B. Instructing the client to wait 4 hours between daytime feedings may result in insufficient milk intake for the newborn and could impact breastfeeding success.
C. Offering supplemental formula between feedings may interfere with establishing breastfeeding and could decrease the client's milk supply.
D. Assessing the newborn's latch while breastfeeding is the appropriate action for addressing sore nipples. Poor latch is a common cause of nipple soreness in breastfeeding mothers. Ensuring the newborn has a proper latch can help alleviate discomfort and prevent further nipple trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Vaginal candidiasis would not typically contraindicate the use of a suppository for constipation.
B. A third-degree perineal laceration involves injury to the anal sphincter and rectal mucosa, making the use of a suppository contraindicated due to the risk of exacerbating the injury and causing further discomfort.
C. Abdominal distention may indicate constipation, which could be a reason for using a suppository, rather than a contraindication.
D. Afterpains, or uterine cramping after childbirth, would not typically contraindicate the use of a suppository for constipation.
Correct Answer is A
Explanation
A. Administering broad-spectrum antibiotics is important because a leaking myelomeningocele increases the newborn’s risk for infection, including meningitis. Early prophylactic antibiotic therapy helps prevent serious complications.
B. Cleansing the site with povidone-iodine is not recommended because antiseptics can irritate neural tissue and worsen leakage. The sac should be kept sterile and moist using a saline-soaked sterile dressing instead.
C. Monitoring rectal temperature is contraindicated because rectal manipulation can risk trauma to the myelomeningocele sac. Noninvasive temperature monitoring, such as axillary measurement, is safer.
D. Surgical closure should be performed as soon as possible, ideally within 24–48 hours after birth, rather than waiting 72 hours, to reduce the risk of infection and further neurologic damage.
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