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 A
Explanation
Choice B rationale:
Giving the wife a straw to help facilitate the client's drinking is not the most appropriate action in this situation. The client's facial paralysis and inability to move his left side could be indicative of a possible stroke or cerebral vascular accident (CVA). Before attempting to give the client fluids, it is essential to assess his swallowing reflex to prevent aspiration and ensure safety. Using a straw may not address the underlying issue.
Choice C rationale:
Assisting the wife and carefully giving the client small sips of water without assessing the swallowing reflex can be risky. If the client has impaired swallowing, this action could lead to aspiration and further complications. Assessing the client's ability to swallow is the priority to ensure safe oral intake.
Choice D rationale:
Obtaining thickening powder before providing any more fluids is premature without first assessing the client's swallowing ability. Thickened liquids may be necessary if the client has dysphagia, but the nurse should assess the client's condition and consult with the healthcare provider before making this decision. Assessing the swallowing reflex is the first step in determining the appropriate course of action.
Correct Answer is ["A","D","E"]
Explanation
The correct answers are:
a) Observe the progression of the seizure.
- Pad the side rails with pillows.
- Loosen clothing around the neck.
Explanation: During a generalized tonic-clonic seizure, it is important for the practical nurse (PN) to prioritize the safety and well-being of the child. The correct actions to implement immediately are:
a) Observe the progression of the seizure: The PN should closely observe the seizure to gather important information that can be helpful for medical professionals in assessing the seizure's characteristics and duration.
- Pad the side rails with pillows: Padding the side rails of the bed with pillows helps to prevent the child
from injuring themselves by hitting the side rails during the seizure.
- Loosen clothing around the neck: Loosening any tight clothing around the child's neck helps to ensure adequate breathing and prevent any constriction or discomfort during the seizure.
- Hold the extremities close to the body: This action is not recommended during a seizure as it may increase the risk of injury to the child or the PN.
- Insert a tongue blade between the teeth: It is not recommended to insert any object, including a tongue blade, between the teeth of a person experiencing a seizure. This can cause injury to the person's mouth or teeth and is no longer considered an appropriate intervention for seizures.
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