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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Free Nursing Study Resources

Correct Answer is ["6"]

Explanation

Heart rate (110/min): 2 points

Respiratory effort (slow, weak cry): 1 point

Muscle tone (some flexion of extremities): 1 point

Reflex irritability (grimace): 1 point

Color (body pink, blue extremities): 1 point

APGAR-6

A. Call the child abuse hotline B. Educate the mother on safety C. Inform the mother to call the nurse for all diaper changes D. Complete the Morse Fall Scale

Correct Answer is A

Explanation

A. Call the child abuse hotline. A spiral fracture, especially in a non-ambulatory infant, is highly suspicious for non-accidental trauma (child abuse). Reporting suspected abuse is mandatory to protect the child from further harm.
B. Educate the mother on safety. While important for prevention, addressing potential abuse takes precedence.
C. Inform the mother to call the nurse for all diaper changes. This does not address the immediate concern of suspected child abuse.
D. Complete the Morse Fall Scale. This is irrelevant in the context of suspected child 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

Correct Answer is ["6"]

Explanation

A newborn is admitted with a diagnosis of a spiral fracture of the right femur. The mother states the child received the injury when the baby fell off the changing table. Which would be the priority nursing intervention?

Correct Answer is A

Explanation

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