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
Explanation
Choice A rationale:
Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.
Choice B rationale:
Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.
Choice C rationale:
Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.
Choice D rationale:
Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.
Correct Answer is D
Explanation
Choice A rationale:
Sinus tachycardia may occur in response to various stressors or physiological conditions but is not directly related to anorexia nervosa or severe malnutrition. It is not the primary pathological process resulting from this condition.
Choice B rationale:
Menstrual cramps are not a pathological process but rather a symptom that may result from hormonal changes or other factors. While amenorrhea (absence of menstrual periods) is a common feature of anorexia nervosa, menstrual cramps are not a primary concern in this context.
Choice C rationale:
Hypertension is not typically associated with anorexia nervosa or severe malnutrition. In fact, individuals with anorexia nervosa often experience hypotension (low blood pressure) due to dehydration and nutritional deficiencies.
Choice D rationale:
Amenorrhea is the primary pathological process resulting from the adolescent's consistent maladaptive behavior of anorexia nervosa. Severe malnutrition and low body weight can disrupt the normal menstrual cycle and lead to amenorrhea. This is a significant concern for individuals with anorexia nervosa and can have long-term health implications.
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