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?
Instruct the client to wait 4 hours between daytime feedings.
Offer supplemental formula between the newborn's feedings.
Have the client limit the length of breastfeeding to 5 minutes per breast.
Assess the newborn's latch while breastfeeding.
Assess the newborn's latch while breastfeeding.
The Correct Answer is D
Sore nipples are a common problem for breastfeeding mothers, especially in the first few days or weeks after delivery. They can cause pain, discomfort, and frustration, and may interfere with breastfeeding success and satisfaction. The most common cause of sore nipples is poor latch, which means that the newborn does not attach to the breast correctly and does not suckle effectively. Poor latch can result from various factors, such as improper positioning, tongue-tie, inverted or flat nipples, engorgement, or thrush.
The nurse should assess the newborn's latch while breastfeeding to identify and correct any problems that may cause sore nipples. The nurse should observe the following signs of a good latch:
- The newborn's mouth is wide open and covers most of the areola (the dark area around the nipple).
- The newborn's chin and nose touch the breast, and the cheeks are rounded and not dimpled.
- The newborn's tongue is visible under the lower lip and curls around the breast.
- The newborn's lips are flanged outwards and not tucked inwards.
- The newborn's jaw moves rhythmically and smoothly, and swallowing sounds are audible.
- The mother feels a gentle tugging sensation on the nipple, but no pain or pinching.
The nurse should also teach the mother how to achieve a good latch by using different positions, supporting the breast with her hand, tickling the newborn's lower lip with her nipple, and bringing the newborn to the breast when their mouth is wide open. The nurse should also encourage the mother to seek help from a lactation consultant or a peer support group if she has persistent or severe nipple pain.
a) Instructing the client to wait 4 hours between daytime feedings is not an appropriate action for the nurse to take. This may reduce nipple soreness temporarily, but it can also cause breast engorgement, milk supply reduction, mastitis, or poor weight gain in the newborn. The nurse should advise the client to feed the newborn on demand, usually every 1.5 to 3 hours during the day and every 3 to 4 hours at night.
b) Offering supplemental formula between the newborn's feedings is not an appropriate action for the nurse to take. This may interfere with breastfeeding initiation and establishment, as it can reduce the mother's milk supply, confuse the newborn's sucking pattern, increase the risk of nipple preference or rejection, and expose the newborn to potential allergens or infections. The nurse should support exclusive breastfeeding for the first six months of life, unless there is a medical indication for supplementation.
c) Having the client limit the length of breastfeeding to 5 minutes per breast is not an appropriate action for the nurse to take. This may not be enough time for the newborn to get enough milk, especially the hindmilk that is richer in fat and calories. It may also prevent proper drainage of the breast and lead to engorgement or mastitis. The nurse should advise the client to let the newborn feed until they are satisfied and release the breast on their own, which may take 10 to 20 minutes per breast on average.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Uterine rupture is a rare but life-threatening complication of labor and delivery that occurs when the uterus tears open along the scar line of a previous cesarean delivery or other uterine surgery¹². Uterine rupture can cause severe bleeding in the mother and deprive the baby of oxygen¹². Some of the signs and symptoms of uterine rupture are:
- Sudden, severe lower abdominal pain
- Drop in blood pressure
- Cool skin and pallor
- Prolonged fetal bradycardia (slow heart rate)
- Loss of fetal station (the baby moves back up the birth canal)
- Abnormal or absent uterine contractions¹²³
Uterine rupture is a medical emergency that requires immediate surgery to deliver the baby and repair the uterus or remove it (hysterectomy)¹².
The other options are incorrect because they have different signs and symptoms:
b) Amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid or fetal cells enter the mother's bloodstream and trigger an allergic reaction. It can cause sudden respiratory distress, cardiac arrest, seizures, or coma in the mother and fetal distress or death in the baby¹². It usually occurs during labor, delivery, or shortly after birth¹².
c) Placenta previa is a condition where the placenta covers part or all of the opening of the cervix. It can cause painless vaginal bleeding during pregnancy or labor¹². It does not affect the blood pressure or fetal heart rate unless there is severe bleeding or placental abruption (separation of the placenta from the uterine wall)¹².
d) Umbilical cord prolapse is a condition where the umbilical cord slips through the cervix and into the vagina before or during labor. It can cause fetal distress, as the cord can become compressed or twisted, cutting off the blood supply and oxygen to the baby¹². It usually causes a sudden drop in fetal heart rate, but does not affect the maternal blood pressure or cause abdominal pain¹².
Correct Answer is B
Explanation
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
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