A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
Have the client limit the length of breastfeeding to 5 min per breast.
Instruct the client to wait 4 hr between daytime feedings.
Offer supplemental formula between the newborn's feedings.
Assess the newborn's latch while breastfeeding.
The Correct Answer is D
Rationale:
A. Limiting the length of breastfeeding to 5 minutes per breast is not recommended and may lead to inadequate milk transfer and supply issues.
B. Instructing the client to wait 4 hours between daytime feedings may result in insufficient milk intake for the newborn and could impact breastfeeding success.
C. Offering supplemental formula between feedings may interfere with establishing breastfeeding and could decrease the client's milk supply.
D. Assessing the newborn's latch while breastfeeding is the appropriate action for addressing sore nipples. Poor latch is a common cause of nipple soreness in breastfeeding mothers. Ensuring the newborn has a proper latch can help alleviate discomfort and prevent further nipple trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. Excessive crying:
Correct answer. Neonatal abstinence syndrome (NAS) often presents with irritability, inconsolable crying, and difficulty soothing.
B. Decreased muscle tone: NAS can cause hypertonia or increased muscle tone rather than decreased muscle tone.
C. Absent Moro reflex: NAS may cause hyperactive Moro reflex rather than absent.
D. Diminished deep tendon reflexes: NAS can cause hyperactive deep tendon reflexes rather than diminished.
Correct Answer is C
Explanation
Rationale:
A. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This scenario does not match the clinical presentation described.
B. Incompetent cervix is characterized by painless cervical dilation in the second trimester and is not relevant to the clinical situation described.
C. Postpartum hemorrhage is a risk when a woman is in advanced labor with significant cervical dilation. The nurse should be vigilant for signs of hemorrhage during labor and after delivery.
D. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy and is not directly related to the client's current labor status.
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