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?
Instruct the client to wait 4 hours between daytime feedings.
Offer supplemental formula between the newborn's feedings.
Have the client limit the length of breastfeeding to 5 minutes per breast.
Assess the newborn's latch while breastfeeding.
Assess the newborn's latch while breastfeeding.
The Correct Answer is D
Sore nipples are a common problem for breastfeeding mothers, especially in the first few days or weeks after delivery. They can cause pain, discomfort, and frustration, and may interfere with breastfeeding success and satisfaction. The most common cause of sore nipples is poor latch, which means that the newborn does not attach to the breast correctly and does not suckle effectively. Poor latch can result from various factors, such as improper positioning, tongue-tie, inverted or flat nipples, engorgement, or thrush.
The nurse should assess the newborn's latch while breastfeeding to identify and correct any problems that may cause sore nipples. The nurse should observe the following signs of a good latch:
- The newborn's mouth is wide open and covers most of the areola (the dark area around the nipple).
- The newborn's chin and nose touch the breast, and the cheeks are rounded and not dimpled.
- The newborn's tongue is visible under the lower lip and curls around the breast.
- The newborn's lips are flanged outwards and not tucked inwards.
- The newborn's jaw moves rhythmically and smoothly, and swallowing sounds are audible.
- The mother feels a gentle tugging sensation on the nipple, but no pain or pinching.
The nurse should also teach the mother how to achieve a good latch by using different positions, supporting the breast with her hand, tickling the newborn's lower lip with her nipple, and bringing the newborn to the breast when their mouth is wide open. The nurse should also encourage the mother to seek help from a lactation consultant or a peer support group if she has persistent or severe nipple pain.
a) Instructing the client to wait 4 hours between daytime feedings is not an appropriate action for the nurse to take. This may reduce nipple soreness temporarily, but it can also cause breast engorgement, milk supply reduction, mastitis, or poor weight gain in the newborn. The nurse should advise the client to feed the newborn on demand, usually every 1.5 to 3 hours during the day and every 3 to 4 hours at night.
b) Offering supplemental formula between the newborn's feedings is not an appropriate action for the nurse to take. This may interfere with breastfeeding initiation and establishment, as it can reduce the mother's milk supply, confuse the newborn's sucking pattern, increase the risk of nipple preference or rejection, and expose the newborn to potential allergens or infections. The nurse should support exclusive breastfeeding for the first six months of life, unless there is a medical indication for supplementation.
c) Having the client limit the length of breastfeeding to 5 minutes per breast is not an appropriate action for the nurse to take. This may not be enough time for the newborn to get enough milk, especially the hindmilk that is richer in fat and calories. It may also prevent proper drainage of the breast and lead to engorgement or mastitis. The nurse should advise the client to let the newborn feed until they are satisfied and release the breast on their own, which may take 10 to 20 minutes per breast on average.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Breast development is a normal part of fetal and neonatal growth. It occurs in stages, starting before birth and continuing during puberty and adulthood. Breast development is influenced by hormones, such as estrogen and progesterone, that are produced by the ovaries or the placenta¹².
Breast development in newborns can vary depending on the gestational age, sex, weight, and exposure to maternal hormones. Some newborns may have palpable breast tissue at birth, while others may develop it later in the first weeks of life. Some newborns may also secrete milk from their breasts, which is called witch's milk or neonatal galactorrhea. This is a harmless and temporary phenomenon that usually resolves within a few weeks without treatment³⁴.
The degree of breast development in newborns can be assessed by using a scoring system that ranges from 0 to 5, based on the size of the areola (the dark area around the nipple) and the presence of a bud (a small lump of glandular tissue under the areola). The scoring system is as follows³:
- Score 0: No breast tissue; flat areola with no bud
- Score 1: Breast tissue < 5 mm; flat areola with no bud
- Score 2: Breast tissue 5 to 10 mm; flat areola with no bud
- Score 3: Breast tissue > 10 mm; raised areola with no bud
- Score 4: Breast tissue > 10 mm; raised areola with bud
- Score 5: Breast tissue > 10 mm; raised areola with large bud
The average score for term newborns is 2.5 for girls and 2.0 for boys. The score tends to be higher for heavier babies and lower for lighter babies. The score also tends to be higher for babies who were exposed to higher levels of maternal hormones during pregnancy, such as those whose mothers had diabetes, preeclampsia, or multiple gestation³⁴.
A score of 0 indicates that there is no breast tissue at all, and the areola is flat with no bud. This finding can indicate preterm gestational age, as breast development usually starts before birth and progresses with increasing gestational age. Preterm newborns may have delayed or incomplete breast development due to insufficient exposure to maternal hormones or immature development of their own hormonal system³⁵.
Therefore, the nurse should identify this finding as indicating preterm gestational age and monitor the newborn for any other signs of prematurity, such as low birth weight, small head size, thin skin, low body temperature, respiratory distress, or feeding difficulties. The nurse should also provide appropriate care and support to the newborn and the parents according to the hospital protocol³⁵.
- b) Ambiguous secondary sex characteristics are physical features that do not clearly match the typical male or female pattern, such as genitalia, hair distribution, or voice pitch. They can be caused by genetic disorders, hormonal imbalances, or environmental influences. Ambiguous secondary sex characteristics do not affect breast development in newborns, as breast tissue is present in both sexes and is influenced by maternal hormones rather than sex hormones¹ .
- c) Decreased maternal hormones during pregnancy can affect breast development in newborns, but not in the way described. Decreased maternal hormones during pregnancy can cause lower breast scores in newborns, as they may have less stimulation of their breast tissue from the placenta. However, this does not mean that they have no breast tissue at all or a flat areola with no bud. They may still have some degree of breast development depending on their gestational age, sex, weight, and exposure to their own hormones³⁴.
- d) Congenital anomaly is a term that refers to any structural or functional abnormality that is present at birth. Congenital anomalies can affect any part of the body and can have various causes, such as genetic mutations, chromosomal abnormalities, infections, drugs, or environmental factors. Congenital anomalies can affect breast development in newborns, but not in the way described. Congenital anomalies that affect breast development in newborns usually cause abnormal or absent nipples or breasts, such as nipple hypoplasia (underdeveloped nipples), athelia (absence of nipples), amastia (absence of breasts), or polymastia (extra breasts). These anomalies do not cause a flat areola with no bud .
Correct Answer is A
Explanation
Urination is an important indicator of a newborn's hydration and kidney function. A newborn should urinate at least six times a day, or once every four hours, by the fifth day of life. The urine should be clear or pale yellow and have no strong odor or blood. A newborn who urinates less than six times a day may be dehydrated, have a urinary tract infection, or have a kidney problem .
Therefore, the nurse should instruct the client to monitor her baby's urination and notify the pediatrician if he urinates less than six times a day. The nurse should also teach the client how to prevent dehydration in her baby, such as:
- Feeding the baby frequently, either breast milk or formula, according to his hunger cues and weight gain
- Offering the baby extra fluids in hot weather or when he is sick
- Avoiding giving the baby water, juice, or cow's milk before six months of age
- Checking the baby's diapers for wetness and changing them promptly
- Checking the baby's mouth for dryness and his fontanelle for sunkenness
The other statements are not correct and should not be made by the nurse:
- b) "Swaddle your baby tightly with his legs extended before laying him down to sleep." This is not correct because swaddling a baby too tightly or with his legs extended can cause problems, such as overheating, hip dysplasia, or restricted breathing. The nurse should teach the client how to swaddle her baby safely and comfortably, such as:
- Using a thin blanket that is breathable and does not cover the baby's head or face
- Wrapping the blanket snugly around the baby's chest and arms, but leaving some room for his hips and legs to move freely
- Placing the baby on his back to sleep on a firm and flat surface with no pillows, blankets, or toys
- Stopping swaddling when the baby shows signs of rolling over or breaking free from the blanket
c) "Place triple antibiotic ointment on your baby's umbilical cord twice per day." This is not correct because placing ointment on the umbilical cord can delay its healing and increase the risk of infection. The nurse should teach the client how to care for her baby's umbilical cord until it falls off naturally, usually within one to two weeks after birth, such as:
- Keeping the cord clean and dry by using a cotton swab dipped in water or alcohol to gently wipe around it
- Folding the diaper below the cord to prevent irritation or wetness
- Dressing the baby in loose-fitting clothes that allow air circulation around the cord
- Avoiding bathing the baby in a tub until the cord falls off and heals
- Watching for any signs of infection, such as redness, swelling, pus, foul odor, or bleeding
d) "Retract the foreskin to clean your baby's penis during each bath." This is not correct because retracting the foreskin of a newborn can cause pain, injury, or infection. The foreskin of a newborn is usually attached to the head of the penis (glans) and does not need to be retracted for cleaning. The nurse should teach the client how to clean her baby's penis during each bath, such as:
- Using warm water and mild soap to gently wash the outside of the penis
- Rinsing well and patting dry with a soft towel
- Leaving the foreskin alone and never forcing it back
- Changing diapers frequently and keeping them clean and dry
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