A client who is one day postpartum reports to the nurse that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?
Offer supplemental formula feedings.
Teach about the use of a breast pump.
Recommend using a breast shield.
Encourage the use of ice on the areola.
The Correct Answer is C
The correct answer is c. Recommend using a breast shield.
Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.
Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.
Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.
Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Choice A rationale:
Increased temperature alone is not a sufficient indication for pain medication in a post-pyloromyotomy infant. Fever can have various causes, and pain should be assessed based on other factors.
Choice B rationale:
Increased pulse rate can be an indication of pain in an infant following surgery like pyloromyotomy. It's important to assess the overall clinical picture and consider pain management if other signs are present.
Choice C rationale:
Increased respiratory rate alone is not a specific indicator of pain in a post-pyloromyotomy infant. Respiratory rate can vary for many reasons, so it should not be the sole criterion for pain management.
Choice D rationale:
Increased pulse rate is a potential sign of pain in a post-pyloromyotomy infant and should be considered when assessing the need for pain medication.
Choice E rationale:
Restlessness is often a sign of discomfort or pain in infants. Restlessness, along with other clinical indicators, can guide the decision to administer pain medication.
Choice F rationale:
Clenched fists can be a sign of discomfort or pain in infants, and it should be considered when assessing the need for pain management.
Correct Answer is C
Explanation
Choice A rationale:
Administering protamine sulfate slowly intravenously within 30 minutes of heparin administration is not the recommended route and timing for reversing heparin's effects. Protamine sulfate is typically given slowly intravenously within 60 minutes of heparin administration.
Choice B rationale:
Administering protamine sulfate rapidly intramuscularly within 60 minutes of heparin administration is not the recommended route for this medication. Protamine sulfate should be given intravenously, not intramuscularly.
Choice C rationale:
Protamine sulfate should be given slowly intravenously within 60 minutes of heparin administration. This is the correct route and timing for reversing the anticoagulant effects of heparin.
Choice D rationale:
Administering protamine sulfate rapidly intramuscularly within 30 minutes of heparin administration is not the recommended route and timing for this medication. Intravenous administration is preferred for a more controlled and predictable reversal of heparin's effects.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today