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.

Offer supplemental formula between the newborn's feedings.

Assess the newborn's latch while breastfeeding.

Instruct the client to wait 4 hr between daytime feedings.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Limiting the length of breastfeeding to 5 minutes per breast may not address the underlying issue of sore nipples and can compromise the newborn's nutritional intake and bonding with the mother.

Choice B rationale:
Offering supplemental formula between feedings is not indicated unless there are specific concerns about the newborn's weight gain or nutritional needs. It does not directly address the issue of sore nipples.

Choice C rationale:
Assessing the newborn's latch while breastfeeding is essential to identify if improper latch or positioning is causing sore nipples. Correcting the latch technique can alleviate the discomfort and promote effective breastfeeding.

Choice D rationale:
Instructing the client to wait 4 hours between daytime feedings may lead to inadequate feeding for the newborn, especially during the early postpartum period when frequent feedings are essential for establishing breastfeeding and ensuring proper milk supply.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should assess this client first as they are at 34 weeks of gestation and experiencing epigastric pain and headache. These symptoms could be indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia requires immediate assessment and intervention to prevent further complications.

Choice B rationale:

Nausea and vomiting are common symptoms during the first trimester of pregnancy, and at 12 weeks of gestation, it is less likely to be a critical issue compared to potential preeclampsia.

Choice C rationale:

Painful urination may indicate a urinary tract infection, which can be important to assess and treat, but it is not as urgent as potential signs of preeclampsia in a client at 34 weeks of gestation.

Choice D rationale:

Cramping and spotting can be normal signs of impending labor, especially at 39 weeks of gestation. While it's important to assess this client, it is not the priority over potential preeclampsia in a client at 34 weeks of gestation with symptoms of epigastric pain and headache.

A. Offer the newborn 30 mL (1 oz) of water between feedings. B. Allow the baby to feed at least every 3 hr. C. Feed the newborn 5 to 10 min per breast. D. Expect two to four wet diapers every 24 hr.

Correct Answer is B

No explanation

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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