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 C
Explanation
Choice A reason: Encourage the client to nurse more frequently so her milk will come in is incorrect, as this action is not related to the data collected by the nurse. The nurse notes that the client's breasts are soft, which indicates that the milk has not come in yet. This is normal and expected for a client who is 14 hr postpartum, as milk production usually begins around 72 to 96 hr after birth. The nurse should encourage the client to nurse frequently and effectively to stimulate milk production and prevent engorgement.
Choice B reason: Increase IV fluids is incorrect, as this action is not indicated by the data collected by the nurse. The nurse notes that the client's vital signs are within normal limits, except for a slight temperature elevation. Increasing IV fluids can cause fluid overload and electrolyte imbalance in the client. The nurse should maintain the IV fluids at the prescribed rate and monitor the client's intake and output.
Choice C reason: Ask the client to empty her bladder is correct, as this action is indicated by the data collected by the nurse. The nurse notes that the client's fundus is firm but slightly deviated to the right, which suggests bladder distension. A full bladder can interfere with uterine contraction and involution and increase the risk of hemorrhage and infection. The nurse should assist the client to empty their bladder and reassess the fundal position.
Choice D reason: Report the client's temperature elevation is incorrect, as this action is not necessary for a slight temperature elevation in a postpartum client. The nurse notes that the client's temperature is 37.7° C (100° F), which is slightly above normal but within the range of expected findings for a postpartum client. A mild temperature elevation in the first 24 hr after birth can be due to dehydration, exertion, or hormonal changes and does not indicate infection. The nurse should encourage oral fluid intake and monitor the temperature every 4 hr.
Correct Answer is B
Explanation
Choice A reason:
Dinoprostone stimulates uterine contractions is incorrect, as this is not the primary purpose of the medication. Dinoprostone is a prostaglandin that can induce labor by ripening the cervix and enhancing uterine contractility, but it is not used solely for stimulating contractions.
Choice B reason:
Dinoprostone promotes softening of the cervix is correct, as this is the main purpose of the medication. Dinoprostone is used to prepare the cervix for labor by increasing its softness, dilation, and effacement. This can facilitate the descent of the fetus and shorten the duration of labor.
Choice C reason:
Dinoprostone relaxes uterine contractions is incorrect, as this is the opposite effect of the medication. Dinoprostone can increase uterine tone and frequency, which can help initiate or augment labor. The nurse should monitor the client for signs of uterine hyperstimulation or fetal distress.
Choice D reason:
Dinoprostone assists with ending the pregnancy is incorrect, as this is not the intended use of the medication. Dinoprostone can be used to terminate a pregnancy in some cases, such as fetal demise or missed abortion, but it is not routinely used for this purpose. The nurse should explain to the client that dinoprostone is used to induce labor and not to end a pregnancy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today