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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fundal consistency is correct, as this finding can indicate the effectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.
Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not affected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.
Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and fluid balance and report any signs of shock or infection.
Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Urinary output can indicate the client's renal function and fluid balance, but it can be influenced by many other factors, such as fluid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.
Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the effectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be influenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and fluid balance and report any signs of hypotension or hypertension.
Correct Answer is B
Explanation
Choice B reason:
A fundus that is elevated and displaced from the midline indicates a full bladder, which can interfere with uterine contraction and increase the risk of hemorrhage. The nurse should assist the client to void or catheterize her if necessary.
Choice A reason:
Moderate swelling of the labia is a normal finding after vaginal delivery, and does not indicate a need to urinate. The nurse should apply ice packs and perineal pads to reduce edema and discomfort.
Choice C reason:
Moderate lochia rubra is a normal finding during the first 24 hr postpartum, and does not indicate a need to urinate. The nurse should monitor the amount and color of lochia, and change the perineal pads as needed.
Choice D reason:
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum client, and does not indicate a need to urinate. The nurse should monitor the blood pressure for signs of hypertension or hypotension, which can indicate complications such as preeclampsia or hemorrhage.
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