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 A

Explanation

A. Administer parenteral antibiotics. The primary concern with premature rupture of membranes (PROM) is the risk of infection, so administering antibiotics is crucial to prevent infection in both the mother and fetus.
B. Prepare for delivery. Without signs of labor, the focus is on preventing infection and monitoring, not immediate delivery.
C. Provide emotional support. While important, the priority intervention is preventing infection.
D. Assess cervical dilation every 6 hours. Routine cervical checks are not typically necessary unless there are signs of labor or other indications.

A. Review clotting studies lab report B. Notify the healthcare provider C. Document the findings in the electronic health record D. Report parents to Child Protective Services

Correct Answer is C

Explanation

A. Review clotting studies lab report: Not relevant to the assessment finding of a blue-gray discoloration.
B. Notify the healthcare provider: Unnecessary unless there are other concerning clinical findings.
C. Document the findings in the electronic health record: A blue-gray discoloration across the sacrum is likely a Mongolian spot, a benign condition more commonly seen in infants of Asian, African, Native American, and Hispanic descent. Documenting this finding in the electronic health record ensures accurate and comprehensive medical documentation without unnecessary interventions.
D. Report parents to Child Protective Services: Inappropriate as this finding is a benign condition common among certain ethnic groups and not indicative of abuse.

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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

An antenatal client at 32 weeks' gestation has been admitted to the hospital with premature rupture of membranes. She is not exhibiting any signs of labor. What is the priority nursing intervention for this client?

Correct Answer is A

Explanation

When performing an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

Correct Answer is C

Explanation

Identify the trimester when each fetal development finding occurs. Note: Each category must have at least 1 response option selected.

You are the nurse caring for an infant with an order to receive Amoxicillin (Amoxil) orally every 6 hours. The safe medication dose is 50mg/kg/day in divided doses. The infant weighs 6 kgs. How much medication will you administer to the infant each dose?

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

Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

When caring for a postpartum client the nurse notes that the client's perineal pad is saturated with bright red blood. What is the priority question to ask the client?

After educating a client on use of a diaphragm for contraception, which statement made by the client demonstrates an understanding of the teaching provided?

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of her son's circumcision care? (Select All that Apply.)

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