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 C

Explanation

The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:

a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.

A. Avoid using lotion or ointment on the newborn's skin. B. Dress the newborn in lightweight clothing. C. Keep the newborn supine throughout treatment. D. Measure the newborn's temperature every 6 hr.

Correct Answer is A

Explanation

Choice A rationale:

When a newborn is receiving phototherapy for hyperbilirubinemia, it is essential to avoid using lotions or ointments on the skin. Phototherapy works by breaking down bilirubin in the skin, and any barriers like lotions or ointments can interfere with this process. The baby's skin needs to be exposed to the light to effectively reduce bilirubin levels.

Choice B rationale:

Dressing the newborn in lightweight clothing is a correct action during phototherapy. The baby should be undressed and placed under the phototherapy lights, with only a diaper on to maximize skin exposure to the light.

Choice C rationale:

Keeping the newborn supine throughout treatment is not a recommended action during phototherapy. To optimize skin exposure to the light, the baby should be placed in a prone position, with the back exposed to the light source.

Choice D rationale:

Measuring the newborn's temperature every 6 hours is essential, but it is not directly related to phototherapy. Temperature monitoring is a routine part of newborn care to assess for signs of infection or other health issues.

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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

A nurse in the labour and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Correct Answer is C

Explanation

A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

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