A nurse is evaluating the use of a nipple shield by a client who is breastfeeding. Which of the following actions by the client demonstrates correct use of the nipple shield?

The client places the nipple shield under the nipple to collect wasted milk.

The client expresses breast milk into the nipple shield for storage.

The client places the nipple shield over the nipple prior to feeding.

The client uses the nipple shield to relieve breast engorgement.

Answer and Explanation

The Correct Answer is C

A. The client places the nipple shield under the nipple to collect wasted milk: The nipple shield is not designed to collect milk. Its primary purpose is to help the infant latch onto the breast more effectively, especially if the mother has difficulty with breastfeeding or if the infant has trouble latching. Placing the nipple shield under the nipple to collect milk would be an incorrect use of the device.
B. The client expresses breast milk into the nipple shield for storage: While expressing breast milk is a common practice, the nipple shield is not intended to be used for milk storage. Its role is to provide a barrier and support to facilitate feeding.
C. The client places the nipple shield over the nipple prior to feeding: This is the correct use of the nipple shield. It is designed to be placed over the nipple before feeding to help the infant latch effectively, especially for mothers with inverted or flat nipples, or when the infant has difficulty latching properly. The nipple shield supports a more effective breastfeeding experience.
D. The client uses the nipple shield to relieve breast engorgement: The nipple shield is not designed to relieve breast engorgement. While it can assist with latching, engorgement typically requires other interventions such as warm compresses, frequent breastfeeding, or expressing milk to alleviate the discomfort and restore normal breast tissue function.

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Correct Answer is A

Explanation

A. Hypothyroidism: Phenylketonuria (PKU) screening helps detect elevated phenylalanine levels, which, if untreated, can lead to irreversible intellectual disability. Early dietary intervention prevents neurodevelopmental delays, a hallmark consequence of untreated PKU that mimics effects seen in congenital hypothyroidism.
B. Growth restriction: While PKU may indirectly affect growth if untreated, the primary concern is neurological damage, not intrauterine or postnatal growth restriction, which is influenced by multiple other factors.
C. Sickle cell anemia: Sickle cell anemia is a genetic blood disorder involving abnormal hemoglobin structure. It is screened for separately from PKU and is unrelated to phenylalanine metabolism.
D. Hypoglycemia: Hypoglycemia in newborns typically results from conditions like maternal diabetes or endocrine disorders. It is not a complication of phenylalanine metabolism and is unrelated to PKU screening.

A. Place the head of the client's bed to 30° for meals. B. Encourage the client to chew on both sides of their mouth. C. Describe food locations as if the client's plate were a clock. D. Provide the client with wide-grip adaptive utensils.

Correct Answer is C

Explanation

A. Place the head of the client's bed to 30° for meals: Elevating the head of the bed to 30° is not sufficient to prevent aspiration in a client who has difficulty eating after a stroke. A 90° angle or as high as tolerated is typically recommended during meals to reduce the risk of aspiration and ensure safe swallowing. A lower elevation increases the chance of food or liquid entering the airway.
B. Encourage the client to chew on both sides of their mouth: Clients who have had a stroke often experience unilateral weakness, including facial and oral muscle weakness. Encouraging them to chew on both sides may not be feasible and can increase the risk of choking if one side of the mouth is significantly paralyzed. Instead, focusing on the stronger side for chewing is safer.
C. Describe food locations as if the client's plate were a clock: This technique is especially helpful for clients with visual field deficits, such as hemianopia, which is common after a stroke. Describing food using the clock method helps orient the client to the location of items on the plate, promoting independence and reducing frustration during meals.
D. Provide the client with wide-grip adaptive utensils: Wide-grip adaptive utensils are beneficial for clients with impaired fine motor skills or limited hand strength, which may occur after a stroke. However, while helpful, this intervention does not directly address the primary issue of difficulty eating due to perceptual or cognitive deficits.

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A nurse is evaluating the use of a nipple shield by a client who is breastfeeding. Which of the following actions by the client demonstrates correct use of the nipple shield?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to screen a newborn for phenylketonuria. The nurse should inform the parents that this screening allows for early detection and intervention to prevent the development of which of the following conditions?

Correct Answer is A

Explanation

A nurse is planning care for a client who had a stroke and is having difficulty eating. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is teaching a client about foods that are high in potassium. The nurse should identify that which of the following foods contains the highest amount of potassium?

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A nurse is reviewing the laboratory findings of a client who has type 1 diabetes mellitus. Which of the following findings should the nurse report to the provider immediately?

A nurse is assessing a client who has a decreased potassium level. Which of the following findings should the nurse expect?

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take to reduce the risk for aspiration?