A nurse is caring for a client who is postpartum and has inverted nipples. Which of the following actions should the nurse take?

Encourage the client to wear an underwire bra.

Have the client apply breast cream on a regular basis.

Provide plastic-lined breast pads.

Place breast shells in the client's bra.

Answer and Explanation

The Correct Answer is D

A. Wearing an underwire bra is not recommended for breastfeeding mothers, especially those with inverted nipples, as it can cause pressure and discomfort, potentially leading to blocked milk ducts and mastitis.
B. Applying breast cream regularly is not specifically beneficial for inverted nipples. It can help with nipple soreness or dryness, but it does not aid in drawing out inverted nipples.
C. Plastic-lined breast pads can help with leakage but do not address the issue of inverted nipples. They do not assist in reshaping or encouraging the protrusion of the nipples.
D. Placing breast shells in the bra can help draw out inverted nipples by applying gentle, consistent pressure around the areola, which encourages the nipples to protrude, making breastfeeding easier for the newborn.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

- Encourage frequent ambulation: Anticipated. Ambulation can help progress labor, unless contraindicated by the healthcare provider.

- Prepare the client for catheterization: Non-essential. There is no current indication for catheterization as the client is voiding adequately and not in active labor.

- Ensure the client maintains a supine position while in bed: Contraindicated. The supine position can cause supine hypotensive syndrome in pregnant clients. A side-lying position is preferred to optimize blood flow.

- Check FHR every 30 min: Anticipated. Regular monitoring of FHR is important to assess fetal well-being during labor.

- Perform a Nitrazine test: Anticipated. Since the client reports fluid leakage, a Nitrazine test can help confirm if the membranes have ruptured.

- Check client's temperature every hour: Non-essential. The client's temperature is stable, and hourly checks are not indicated unless there are signs of infection or the membrane has been ruptured for an extended period.

- Obtain CBC blood sample: Anticipated. A CBC can help identify any underlying issues such as anemia or infection that could affect labor and delivery.

A. The newborn's legs flex at the knees and hips when pressure is applied to the soles of the newborn's feet. B. The newborn turns their head away from the stimulus when their cheek is touched. C. The newborn's fingers curl around the nurse's finger when placed in the newborn's palm. D. The newborn closes their eyes and keeps them closed when tapped on the forehead.

Correct Answer is C

Explanation

A. This describes the stepping reflex, which involves the newborn's legs moving in a stepping motion when the soles of the feet touch a surface, not just flexing at the knees and hips. It is expected but not the most relevant to the of reflex elicitation as stated.
B. The newborn turns toward the stimulus when their cheek is touched, not away. This is known as the rooting reflex, which helps the newborn find the breast or bottle for feeding.
C. The newborn's fingers curling around the nurse's finger is the grasp reflex, a normal and expected finding in newborns. It indicates normal neurological development and reflex activity.
D. The newborn blinking in response to a tap on the forehead is known as the glabellar reflex, but they do not typically keep their eyes closed. It is not a primary reflex assessed in newborns for neurological health.

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A nurse is caring for a client who is postpartum and has inverted nipples. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

Correct Answer is C

Explanation

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