A client who is one day postpartum reports to the nurse 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 is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.

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Correct Answer is D

Explanation

Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.

Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.

Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.

Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.

A. Promote full diaphragmatic excursion by massaging the back. B. Assist the client to a chair the day after surgery when the condition is stable. C. Note areas of atelectasis on the daily chest x-rays. D. Provide ice or oral liquids when the client passes flatus.

Correct Answer is B

Explanation

Choice A reason: Massaging the back to promote diaphragmatic excursion can be beneficial but is not the most effective intervention compared to early mobilization.

Choice B reason: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.

Choice C reason: Noting areas of atelectasis on chest x-rays is important for monitoring, but it is not an intervention that actively prevents respiratory complications.

Choice D reason: Providing ice or oral liquids when the client passes flatus is related to gastrointestinal recovery, not respiratory complications.

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A client who is one day postpartum reports to the nurse 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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