A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

Offer supplemental formula feedings.

Teach about the use of a breast pump.

Recommend using a breast shield.

Encourage the use of ice on the areola.

Answer and Explanation

The Correct Answer is C

Choice A reason: Offering supplemental formula feedings may not be the best initial approach for inverted nipples as it could lead to nipple confusion and interfere with breastfeeding.

Choice B reason: While teaching about the use of a breast pump is helpful for expressing milk, it does not directly address the issue of latching with inverted nipples.

Choice C reason: A breast shield can be beneficial for mothers with inverted nipples as it can help draw out the nipple, allowing the baby to latch on more effectively.

Choice D reason: Using ice on the areola is not a recommended practice for addressing inverted nipples as it can cause discomfort and is not a reliable method for improving latch.

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Correct Answer is B

Explanation

Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.

Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.

Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.

A. "The healthcare provider will share this information with you." B. "I can only give medical information to your child because the client is an adult." C. "I'm sorry, but your child's medical information is none of your business." D. "I can give you those results as soon as I get them back from the lab."

Correct Answer is B

Explanation

Choice A reason:Deferring to the provider does not address the confidentiality issue; it suggests the nurse is unwilling rather than clarifying the legal obligation to protect an adult client’s health information.

Choice B reason: By stating that only the client can authorize release of their own medical data, the nurse accurately reflects HIPAA and patient‑privacy regulations for an adult. This response both informs the parent and upholds the client’s right to confidentiality.

Choice C reason: This response is inappropriate and unprofessional. It fails to acknowledge the parent's concern and does not provide a constructive way to address the situation.

Choice D reason: While this response may seem helpful, it is not the nurse's role to promise lab results, especially when there are privacy laws that restrict the sharing of medical information with anyone other than the patient unless consent has been given.

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A client who is one day postpartum reports that her baby cannot latch onto the breast. The nurse observes that the client's nipples are inverted. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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