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. Muscle weakness: Potassium is essential for normal neuromuscular function, and a low serum potassium level disrupts muscle cell excitability and contractility. As a result, clients may present with generalized weakness, particularly in the lower extremities, and may have difficulty with mobility or respiration if the weakness progresses.
B. Hyperreflexia: Hyperreflexia is more commonly associated with elevated calcium or magnesium imbalances rather than decreased potassium. Hypokalemia typically causes reduced neuromuscular excitability, which would result in diminished or absent reflexes rather than increased reflex activity. Therefore, hyperreflexia is not an expected finding in a client with low potassium.
C. Chvostek's sign: Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It is elicited by tapping the facial nerve, resulting in twitching of the facial muscles. This sign indicates increased neuromuscular excitability due to low calcium levels, which is unrelated to potassium regulation. It is not expected in cases of decreased potassium.
D. Seizures: Seizures are more commonly linked with abnormalities in sodium or calcium levels, particularly hyponatremia or severe hypocalcemia. While severe hypokalemia can lead to cardiac arrhythmias and muscle paralysis, it is not typically associated with seizures. Therefore, seizures are not a standard finding in clients with hypokalemia.

A. Elevated erythrocyte sedimentation rate (ESR) B. Increased bilirubin levels C. Guaiac fecal occult blood test positive D. Weight gain 1.6 kg (3.5 lb)

Correct Answer is D

Explanation

A. Elevated erythrocyte sedimentation rate (ESR): An elevated ESR is a nonspecific marker of inflammation. It can be elevated due to a variety of conditions, including infection, autoimmune disease, or chronic illness. In TPN, this finding would require further evaluation but is not a definitive or immediate indicator of a TPN-related complication.
B. Increased bilirubin levels: While increased bilirubin levels may suggest liver dysfunction, they are not uncommon in clients receiving TPN over an extended period due to hepatobiliary complications like cholestasis. However, after just 24 hours of TPN, a rise in bilirubin is unlikely to occur this quickly as a result of TPN alone.
C. Guaiac fecal occult blood test positive: A positive fecal occult blood test indicates the presence of gastrointestinal bleeding, which is not a typical complication associated with TPN initiation. While it is a concerning clinical finding, it is not directly linked to the use of TPN and may be related to other underlying gastrointestinal issues that need separate investigation.
D. Weight gain 1.6 kg (3.5 lb): A rapid weight gain of this magnitude within 24 hours of starting TPN suggests fluid overload, which is a potential complication of TPN therapy especially in clients with compromised cardiac or renal function. This finding indicates the need for immediate intervention to prevent further complications such as pulmonary edema or hypertension.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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