A nurse is caring for a client who is one day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Have the client limit the length of breastfeeding to 5 minutes per breast.

Assess the newborn’s latch while breastfeeding.

Instruct the client to wait 4 hours between daytime feedings.

Offer supplemental formula between the newborn’s feedings.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Limiting the length of breastfeeding to 5 minutes per breast is not typically recommended. It’s important for the baby to empty each breast completely, as the fat content of the milk increases as the breast empties.
Choice B rationale
Assessing the newborn’s latch while breastfeeding is crucial. A poor latch can cause sore nipples. The baby should take as much of the areola into their mouth as possible, with more areola showing at the top lip than the bottom.
Choice C rationale
Waiting 4 hours between daytime feedings is not typically recommended for a breastfeeding newborn. Newborns typically need to feed every 2-3 hours, or 8-12 times in 24 hours.
Choice D rationale
Offering supplemental formula between the newborn’s feedings can interfere with establishing a good milk supply and should be avoided unless medically necessary.

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Correct Answer is A

Explanation

Choice A rationale
If a nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage after a cesarean birth, administering a 500 mL lactated Ringer’s IV bolus can help increase the client’s circulating volume and support her hemodynamic stability. This is often the first step in managing postpartum hemorrhage.
Choice B rationale
While evaluating urinary output is an important aspect of postoperative care, it would not directly address the issue of ongoing vaginal bleeding.
Choice C rationale
Applying an ice pack to the incision site can help reduce swelling and provide some pain relief, but it would not address the issue of vaginal bleeding.
Choice D rationale
Replacing the surgical dressing is part of routine postoperative care, but it would not directly address the issue of ongoing vaginal bleeding.

A. Assist the client in pulling their knees toward their abdomen. B. Press firmly on the client’s suprapubic area. C. Apply pressure to the client’s fundus. D. Move the client onto their hands and knees.

Correct Answer is A

Explanation

In the event of shoulder dystocia during the second stage of labor, the provider may instruct the nurse to perform the McRoberts maneuver. This involves assisting the client in pulling their knees toward their abdomen. This position effectively flattens the sacrum, changes the angle of the pelvic inlet, and allows more room for the baby to pass through the birth canal.

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A nurse is caring for a client who is one day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago.Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply)

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

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