Which three (3) assessment findings indicate that the breastfeeding client has achieved a proper latch?

Rhythmic suckling

A slurping sound as the infant sucks

Tongue down with lips flanged

Dimpling of the infant's cheeks while sucking

Audible swallowing

Answer and Explanation

Correct Answer : A,C,E

A. Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing. Indicates milk transfer is occurring as the infant swallows.

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Correct Answer is D

Explanation

A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.

A. A 10-year-old with a burn on the palm of the hand B. A 6-year-old with splash burns on the front torso C. A 4-year-old with circular abrasions around the wrists D. A 2-year-old with a large bruise on the forehead

Correct Answer is C

Explanation

A. A 10-year-old with a burn on the palm of the hand: This could potentially be accidental, for example, from touching a hot surface. However, while it requires further investigation, it is not as strongly indicative of abuse as the given option.
B. A 6-year-old with splash burns on the front torso: These burns could result from accidentally spilling hot liquids. Though it raises concern, it often indicates an accident rather than abuse unless accompanied by other suspicious signs.
C. A 4-year-old with circular abrasions around the wrists: This is highly suspicious of abuse because circular abrasions can indicate that the child may have been tied or restrained, which is not typical of accidents or normal play.
D. A 2-year-old with a large bruise on the forehead: This type of injury is common in young children who are prone to falls and bumps. It might not immediately suggest abuse without additional context.

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Which three (3) assessment findings indicate that the breastfeeding client has achieved a proper latch?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?

Correct Answer is D

Explanation

Which of the following clients would the nurse report as a suspected abuse case?

Correct Answer is C

Explanation

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