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?
offer supplemental formula between the newborn's feedings.
Have the client limit the length of breastfeeding to 5 min per breast.
Instruct the client to wait 4 hr between daytime feedings.
Assess the newborn's latch while breastfeeding.
The Correct Answer is D
This
suggests that the nurse should assess the newborn's latch while breastfeeding. Sore nipples are a common concern among breastfeeding mothers, and the most common cause is an improper latch. The nurse should ensure that the baby is latching on correctly and not causing trauma to the mother's nipples. A proper latch involves the baby taking in a good portion of the areola and not just the nipple. Assessing the newborn's latch can help identify any issues with the baby's mouth or tongue that may be causing difficulty latching on. If the baby is not latching correctly, the nurse can provide education and support to help the mother correct the issue. Offering supplemental formula between feedings (choice A) is not recommended as it can decrease the frequency of breastfeeding and reduce the stimulation for milk production, leading to decreased milk supply. Instructing the client to wait 4 hours between daytime feedings (choice C) is not recommended as it can decrease milk production and lead to inadequate nutrition for the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Lentils. Lentils have the highest fiber content per cup compared to the other options. One cup of cooked lentils provides approximately 15.6 grams of fiber. Oatmeal provides approximately 4 grams of fiber per cup, asparagus provides approximately 3.6 grams of fiber per cup, and cabbage provides approximately 2.6 grams of fiber per cup. Increasing dietary fiber is an effective way to manage constipation during pregnancy, as it can promote bowel regularity and prevent complications such as hemorrhoids. The nurse can provide additional education on other high-fiber food options, the importance of drinking adequate fluids, and the need to increase physical activity to help manage constipation. 
Correct Answer is C
Explanation
A. Discomfort in the lower back (sacral area) is common during labor, particularly during contractions. This is not an unusual finding that would require immediate reassessment.
B. Contractions lasting between 45 to 60 seconds are typical during the active phase of labor. This duration of contractions is expected as labor progresses, and does not require immediate reassessment.
C. This sensation can indicate that the fetus has descended into the birth canal and may be a sign that the client is entering the second stage of labor, or is close to delivery. This requires immediate reassessment by the nurse to check for full cervical dilation and fetal descent.
D. Emotional excitement and changes in skin temperature are typical responses during labor due to the physiological and emotional aspects of childbirth. This does not indicate the need for immediate reassessment.
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