A nurse is assisting in the care of a client who is in labor.
The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to
mean which of the following?

Choice A rationale:

When breastfeeding, it’s important for the baby to latch onto not just the nipple, but also some of the areola, which is the

darker circle of skin around the nipple. This allows the baby to get a deep latch, which is necessary for effective breastfeeding.

The baby’s chin should be firmly touching the breast, and their mouth should be wide open. When they attach, you should see

much more of the darker nipple skin above the baby’s top lip than below their bottom lip.

Choice B rationale:

While it’s true that babies have certain instincts when it comes to breastfeeding, they still need guidance and proper

positioning to latch correctly. Simply relying on the baby’s instincts may not ensure a proper latch, which could lead to

ineffective breastfeeding and potential discomfort for the mother.

Choice C rationale:

The size of the baby’s mouth does not determine how much of the nipple they should take in. Regardless of the size of the

baby’s mouth, they should still latch onto the nipple and some of the areola for effective breastfeeding. Taking only part of the

nipple could lead to a shallow latch, which can cause nipple pain and may not allow the baby to get enough milk.

Choice D rationale:

While it’s important for the baby to take in a good amount of the breast tissue, including the nipple and areola, during

breastfeeding, suggesting to include some breast tissue beyond the areola might be excessive. The key is to ensure a deep

latch, which typically involves the nipple and some of the areola, rather than the entire areola and additional breast tissue.

Choice A rationale:

Placing pillows under the client's knees can actually increase the risk of thrombophlebitis. This is because it flexes the knees,

which can cause blood to pool in the legs. This pooling of blood can lead to the formation of blood clots.

Choice B rationale:

Keeping the client on bed rest is also a risk factor for thrombophlebitis. This is because immobility can cause blood to pool in

the legs. It's important to encourage early and frequent ambulation to promote venous return and prevent clot formation.

Choice C rationale:

Applying warm, moist soaks to the client's lower legs can help to relieve the symptoms of thrombophlebitis, but it does not

prevent it. Warm compresses can help to improve circulation and reduce inflammation, but they're not a preventative

measure.

Choice D rationale:

Encouraging the client to ambulate frequently is the most effective way to prevent thrombophlebitis. This is because it helps to

promote venous return and prevent blood from pooling in the legs. Ambulation also helps to activate the calf muscles, which

act as a natural pump to help move blood back to the heart.