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
Maternal hypotension is a common complication of spinal anesthesia for cesarean section, and it can cause adverse effects on the mother and the fetus, such as nausea, vomiting, dizziness, decreased placental perfusion, fetal acidosis, and fetal distress¹². To prevent or treat maternal hypotension, various techniques have been used, such as fluid preloading or co-loading, vasopressors, lower limb compression devices, and left lateral tilt position¹². Among these, fluid administration is the most widely used and recommended
intervention¹²³. A bolus infusion of lactated Ringer's or other crystalloid solution can increase the intravascular volume and cardiac output, and counteract the decrease in blood pressure caused by spinal anaesthesia¹²³. The optimal timing and amount of fluid administration may vary depending on the individual patient's condition and response, but generally a bolus of 10 to 20 mL/kg is suggested before or during spinal anaesthesia¹²³.
The other options are incorrect because:
b) Applying oxygen via nonrebreather face mask at 2 L/min is not an effective intervention for maternal hypotension. Oxygen supplementation may be beneficial for improving fetal oxygenation in case of fetal distress, but it does not directly increase maternal blood pressure or cardiac output¹². Moreover, 2 L/min is a low flow rate for a nonrebreather face mask, which requires at least 10 L/min to deliver high concentrations of oxygen⁴.
c) Positioning the client in a knee-chest position is not a recommended intervention for maternal hypotension. This position may increase venous return and cardiac output in some cases, but it also increases intra-abdominal pressure and reduces uterine blood flow, which can compromise fetal oxygenation and well-being. A left lateral tilt position of 15 to 30 degrees is preferred to avoid aortocaval compression and improve placental perfusion¹².
d) Giving terbutaline subcutaneously is not an appropriate intervention for maternal hypotension. Terbutaline is a beta-agonist that relaxes the uterine smooth muscle and prevents preterm labor contractions. It has no direct effect on maternal blood pressure or cardiac output, and it may cause maternal tachycardia, palpitations, tremors, and hypokalemia as side effects. Vasopressors such as ephedrine or phenylephrine are more effective and safer drugs for treating maternal hypotension¹².
Correct Answer is B
Explanation
Among the given options, the client who is at 34 weeks of gestation and experiencing epigastric pain and headache should be assessed first. Epigastric pain and headache can be signs of preeclampsia, a serious condition characterized by high blood pressure and organ dysfunction during pregnancy. Preeclampsia requires immediate attention as it can lead to complications for both the mother and the fetus.
Option a) A client at 12 weeks of gestation experiencing nausea and vomiting may be experiencing normal symptoms of early pregnancy. While it is important to assess the client's well-being, it is not an immediate priority compared to the potential signs of preeclampsia in option b.
Option c) A client at 38 weeks of gestation experiencing painful urination may indicate a urinary tract infection (UTI). While a UTI should be addressed, it does not pose the same level of immediate risk as the potential signs of preeclampsia in option b.
Option d) A client at 39 weeks of gestation experiencing cramping and spotting may be in early labor or have other signs of impending labor. While it is important to assess this client's condition, it is not an immediate priority compared to the potential signs of preeclampsia in option b.
Therefore, the nurse should assess the client who is at 34 weeks of gestation and experiencing epigastric pain and headache as the first priority. Prompt evaluation and management of preeclampsia symptoms are crucial to prevent complications and ensure the well-being of both the mother and the fetus.
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