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 B
Explanation
A. Monitor the rectal temperature every 4 hr: Rectal temperature measurement is contraindicated in this newborn due to the risk of trauma to the spinal cord or irritation of the leaking sac. Axillary temperature monitoring is a safer alternative.
B. Administer broad-spectrum antibiotics: Broad-spectrum antibiotics help prevent infection from organisms entering through the exposed or leaking sac. This is a priority intervention to ensure the safety of the newborn.
C. Cleanse the site with povidone-iodine: Povidone-iodine is not recommended for cleansing the sac, as it can cause irritation or toxicity. Instead, the sac should be kept clean and moist with a sterile, saline-soaked dressing.
D. Prepare for surgical closure after 72 hr: Surgical closure of the defect is typically performed within 24 to 48 hours after birth to minimize infection risk and prevent further damage to neural tissue. Waiting beyond this window is not standard practice for a leaking myelomeningocele.
Correct Answer is D
Explanation
The correct answer is choice D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score." components of the Apgar score:
|
Component |
0 Points |
1 Point |
2 Points |
|
Heart Rate |
Absent |
<100 bpm |
>100 bpm |
|
Respiratory Effort |
Absent |
Slow, irregular |
Good, crying |
|
Muscle Tone |
Flaccid |
Some flexion |
Active motion |
|
Reflex Irritability |
No response |
Grimace |
Vigorous cry |
|
Color |
Blue, pale |
Body pink, extremities blue |
Completely pink |
The score for each component is summed up to a maximum score of 10, with 10 indicating the healthiest newborn. The NRP guidelines emphasize that resuscitation efforts should be initiated immediately after delivery, regardless of the Apgar score, thus choice C is wrong.
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