Which three assessment findings indicate that the breastfeeding client has achieved a proper latch?
A slurping or clicking sound as the infant sucks.
Audible swallowing.
Infant's tongue cups under the breast with lips flanged.
The mother can see a rhythmic sucking pattern.
Dimpling of the infant's cheeks while sucking.
Correct Answer : B,C,D
Choice A rationale
A slurping or clicking sound indicates poor latching and is often associated with air entering the mouth due to improper seal or positioning of the infant. These sounds can reflect nipple misalignment or inadequate breast tissue placement into the infant's mouth, affecting milk transfer and leading to potential breastfeeding complications, such as nipple pain or reduced milk intake.
Choice B rationale
Audible swallowing confirms that the infant is successfully transferring milk and is properly latched. Proper latch allows efficient milk removal, which triggers swallowing reflexes. It reflects an absence of air entry and indicates that the infant is receiving milk without difficulty, promoting both nutritional intake and breastfeeding success.
Choice C rationale
The infant's tongue cupping under the breast with lips flanged ensures proper latch by creating a vacuum seal. This position prevents air leakage and allows effective milk transfer. Tongue cupping and lip flanging optimize compression of the lactiferous sinuses, supporting effective breastfeeding and minimizing discomfort for the mother.
Choice D rationale
Rhythmic sucking is a sign of coordinated latch and feeding. It reflects successful milk transfer and synchronization between suckling and swallowing. Rhythmic patterns reduce the risk of nipple trauma by ensuring proper placement and suction. This indicates that breastfeeding dynamics are efficient and beneficial.
Choice E rationale
Dimpling of the infant's cheeks occurs due to suction difficulties and often signifies improper latch or weak oral musculature. It leads to air leakage and insufficient milk removal. This finding may contribute to feeding inefficiencies and nipple trauma, indicating a need for latch correction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Alcohol swabs are not recommended for cleaning the circumcision site as they may irritate the delicate tissue and delay healing. Proper care involves gentle cleansing with water and avoiding substances that can cause discomfort or tissue damage.
Choice B rationale
While monitoring for bleeding is essential, small spots of blood on the diaper may be normal. Excessive bleeding, however, is a cause for concern and should prompt immediate medical consultation, emphasizing the need to differentiate normal healing signs from complications.
Choice C rationale
A loose diaper reduces pressure on the circumcision site and prevents friction, which could cause pain or disrupt the healing process. This practice ensures the Plastibell stays in position until it detaches naturally, minimizing discomfort and promoting tissue recovery.
Choice D rationale
The Plastibell typically falls off within 5 to 8 days, not within 24 hours. Misunderstanding this timeframe can cause undue anxiety for parents or lead to premature removal attempts, which may complicate the healing process or cause injury to the site.
Correct Answer is B
Explanation
Choice A rationale
Teaching the child how to use an inhaler supports self-management but does not address developmental readiness for independent inhaler use. At five years old, children often require supervision due to incomplete cognitive and motor development.
Choice B rationale
Providing information to the caregiver about child development stages clarifies expectations for independent inhaler use. This knowledge aligns with the protective factor of ensuring developmentally appropriate interventions for pediatric asthma management.
Choice C rationale
Community resources offer support but do not directly relate to the child's ability to use the inhaler without supervision. While beneficial, this option does not prioritize the developmental readiness aspect of pediatric care.
Choice D rationale
Referring the caregiver to an asthma educator focuses on skill-building and education but overlooks the specific developmental readiness of the child. Direct caregiver education on developmental milestones is more impactful in this context. .
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