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 D
Explanation
The correct answer is choice D. Urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate. Magnesium sulfate is a medication used to treat preeclampsia, a potentially life-threatening condition that can occur during pregnancy. Adverse reactions to magnesium sulfate include hypotension, respiratory depression, and decreased urine output. The nurse should monitor the client's vital signs and urine output closely while the client is receiving magnesium sulfate. Normal urine output in a healthy individual should be between 0.5-1.5 mL/kg/hour, and patients should generally be urinating at least every 6 hours.
Correct Answer is C
Explanation
A. Right upper quadrant: This is not the correct location for hearing the fetal heart rate in the LOA position, as it is on the opposite side and higher than expected.
B. Left upper quadrant: The fetal heart rate in the LOA position is heard below, not above, the maternal umbilicus.
C. Left lower quadrant: The PMI of the fetal heart rate is best heard in the left lower quadrant when the fetus is in the left occipitoanterior position, as the fetal back (closest to the heart) is located on the left side and positioned anteriorly.
D. Right lower quadrant: This site is appropriate for a right occipitoanterior (ROA) fetal position, not LOA.
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