The nurse is caring for a patient who is two days postpartum and exclusively breastfeeding. Upon assessment, the patient has cracked nipples and a painful latch. What will the nurse include in the patient's plan of care?

Begin formula supplementation

Cleanse the breast with soap and water

Reposition the baby

Administer ibuprofen

Answer and Explanation

The Correct Answer is C

Choice A reason: Beginning formula supplementation is not the first step in addressing issues with breastfeeding. Introducing formula might reduce the infant’s breastfeeding efficiency and disrupt milk supply. The focus should initially be on correcting the breastfeeding technique to ensure successful and comfortable breastfeeding for both mother and baby.

Choice B reason: Cleansing the breast with soap and water is not recommended as it can dry out the nipples and exacerbate cracking. It is more appropriate to clean the breasts with warm water and avoid harsh soaps that could strip natural oils and worsen nipple damage.

Choice C reason: Repositioning the baby is a crucial step in addressing breastfeeding issues such as cracked nipples and a painful latch. Ensuring a proper latch can significantly reduce nipple trauma and improve comfort during breastfeeding. Techniques like ensuring the baby’s mouth covers more areola and changing breastfeeding positions can help achieve a better latch.

Choice D reason: Administering ibuprofen may help relieve pain temporarily, but it does not address the root cause of the breastfeeding issue. The primary focus should be on correcting the baby's latch and positioning to prevent ongoing nipple damage and pain during breastfeeding. Pain management should be considered alongside addressing the underlying problems.

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Correct Answer is ["1"]

Explanation

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

A. Schedule a full neurological evaluation. B. Recommend follow-up in 30 days after documenting the regression. C. Question the parents about changes in the child's activity schedule. D. Document the findings and schedule an 18-month well-visit.

Correct Answer is A

Explanation

Choice A reason: Scheduling a full neurological evaluation is the appropriate action in this scenario. The sudden regression in the child's ability to walk is a significant concern that requires immediate investigation to rule out any underlying neurological or medical conditions. A full neurological evaluation will help identify any issues such as developmental delays, neuromuscular disorders, or other conditions that may be affecting the child's motor skills. Prompt evaluation and diagnosis are crucial for early intervention and appropriate management.

Choice B reason: Recommending follow-up in 30 days after documenting the regression is not an ideal approach in this situation. Given the severity of the regression in the child's walking ability, waiting for 30 days without further investigation could delay critical diagnosis and treatment. Immediate assessment is necessary to address potential underlying issues and provide timely intervention.

Choice C reason: Questioning the parents about changes in the child's activity schedule is important but should not be the sole action taken. While gathering information about the child's activities and environment can provide valuable context, it does not replace the need for a thorough medical evaluation. The primary concern here is the sudden regression in motor skills, which warrants a full neurological assessment.

Choice D reason: Documenting the findings and scheduling an 18-month well-visit is also not sufficient. While it is essential to document the observed regression, delaying further action until the next routine check-up could result in missed opportunities for early diagnosis and intervention. The priority should be to conduct a neurological evaluation to understand the cause of the regression and take appropriate steps to address it.

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The nurse is caring for a patient who is two days postpartum and exclusively breastfeeding. Upon assessment, the patient has cracked nipples and a painful latch. What will the nurse include in the patient's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

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Correct Answer is A

Explanation

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