A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

"Babies know instinctively exactly how much of the nipple to take into their mouth."

"Your baby's mouth is rather small so she will only take part of the nipple."

"Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth."

"You should place your nipple and some of the areola into her mouth."

Answer and Explanation

The Correct Answer is D

Choice A reason: "Babies know instinctively exactly how much of the nipple to take into their mouth." is incorrect, as this response does not provide adequate guidance or support for the client. Babies may not always latch on correctly or eﬀectively, especially in the first few atempts. The nurse should teach the client how to position and latch the baby properly and observe for signs of eﬀective breastfeeding.

Choice B reason: "Your baby's mouth is rather small so she will only take part of the nipple." is incorrect, as this response can lead to ineﬀective breastfeeding and nipple trauma. Taking only part of the nipple can cause poor milk transfer, inadequate milk production, and nipple soreness or cracking. The nurse should teach the client how to ensure that the baby takes enough of the nipple and areola into their mouth.

Choice C reason: "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth." -Including too much breast tissue can be uncomfortable. While some areola is important, including too much breast tissue can hinder proper latch and milk flow.

Choice D reason: "You should place your nipple and some of the areola into her mouth." This accurately describes the ideal latch for breastfeeding. Including some of the areola helps the baby latch deeply and comfortably, promoting milk transfer and preventing feeding difficulties and nipple soreness.

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Correct Answer is D

Explanation

Choice D reason:
Placing the client in a knee-chest or Trendelenburg position is the first action the nurse should take, as it can relieve pressure on the cord and prevent compression and fetal hypoxia. The nurse should also use a sterile gloved hand to hold the presenting part oﬀ the cord.

Choice A reason:
Preparing the client for an emergency cesarean birth is an important action, as it can facilitate prompt delivery and prevent fetal compromise. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.

Choice B reason:
Covering the cord with a sterile, moist saline dressing is an important action, as it can prevent drying and infection of the cord. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord compression.

Choice C reason:
Explaining to the client what is happening is an important action, as it can provide emotional support and education for the client. However, this is not the first action the nurse should take, as it does not address the immediate problem of cord prolapse.

A. Urinary output 2,000 mL/12 hr B. Temperature 100.4 F for two days C. Chills shortly following delivery D. Fundus at umbilicus level

Correct Answer is B

Explanation

Choice A reason:

A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body eliminates excess ﬂuid accumulated during pregnancy.

Choice B reason:

A temperature of 100.4 F for two days indicates a possible infection, such as endometritis or mastitis, and requires further evaluation and treatment.

Choice C reason:

Chills shortly following delivery are common and benign and are caused by hormonal changes and ﬂuid shifts.

Choice D reason:

A fundus at the umbilicus level is expected for a postpartum client and indicates that the uterus is involuting properly.

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A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor patern has been established. Which of the following explanations should the nurse include?

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate?

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes breasts soft, fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?