The nurse is assessing a 3-day-postpartum breastfeeding woman.
Her breasts are firm and warm to touch.
When asked when she last fed the infant, her reply is, "I fed the baby last evening, but I let the nurses feed him in the nursery last night because I needed to rest.”. Which action would the nurse take to prevent the woman from developing mastitis?
Obtain a prescription to culture her expressed breast milk.
Have the woman massage her breasts hourly.
Encourage the woman to breastfeed her infant more frequently.
Instruct the woman to increase her fluid intake.
The Correct Answer is C
Choice A rationale
Obtaining a culture of expressed breast milk is not indicated at this stage because the assessment findings of firm, warm breasts suggest physiological engorgement rather than an active infectious process. Mastitis typically presents with systemic symptoms like fever, chills, and localized wedge-shaped erythema. Since the primary issue is milk stasis due to skipped nighttime feedings, a culture would be premature and clinically unnecessary unless symptoms of infection fail to resolve with proper emptying.
Choice B rationale
Frequent hourly massage of the breasts is not a recommended primary intervention for preventing mastitis and could potentially lead to tissue trauma or increased inflammation if performed too aggressively. While gentle massage during feeding can assist with milk let-down and emptying, doing so hourly without accompanying drainage through breastfeeding or pumping does not address the underlying issue of milk stasis. The focus must remain on the consistent and effective removal of milk from the mammary ducts.
Choice C rationale
Increasing the frequency of breastfeeding is the most effective way to prevent mastitis by ensuring regular emptying of the mammary glands. Milk stasis is the primary precursor to mastitis, as stagnant milk provides a medium for bacterial growth and causes intraductal pressure. By feeding more often, the mother reduces engorgement and maintains a healthy flow. The normal frequency for breastfeeding is usually 8 to 12 times in a 24-hour period to ensure adequate breast drainage.
Choice D rationale
Increasing fluid intake is generally beneficial for overall maternal hydration and health but does not directly prevent the development of mastitis caused by milk stasis. Mastitis is a mechanical and infectious issue related to how well the breasts are being emptied rather than the mother's systemic hydration status. While maintaining a high fluid intake supports milk volume, it cannot compensate for the lack of physical milk removal during long intervals between infant feedings at the breast.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Allowing a child to cry alone, often referred to as the cry it out method, is not recommended for neonates or infants immediately after birth. Scientific evidence suggests that prompt responses to an infant's distress signals are essential for developing a secure attachment and building foundational trust. Ignoring a newborn's cries can lead to increased cortisol levels and psychological stress, which negatively impacts the delicate neurological development and emotional bond between the mother and the infant.
Choice B rationale
Newborns require constant closeness and physical contact to regulate their physiological systems, such as heart rate, temperature, and breathing. Suggesting that a mother needs time alone to avoid overwhelming the child is scientifically inaccurate in the context of healthy bonding. Isolation during the immediate postpartum period can lead to maternal detachment or postpartum depression. The biological expectation of a newborn is continuous proximity to the caregiver to ensure survival and optimal emotional health through sensory stimulation.
Choice C rationale
Reciprocal interactions like holding, skin to skin contact, and gentle vocalization stimulate the release of oxytocin in both the mother and the newborn. Oxytocin is a hormone critical for social bonding and maternal behavior. These sensory inputs facilitate the transition to extrauterine life for the infant and help the mother develop confidence in her caregiving abilities. Engaging in these behaviors strengthens the neurobiological pathways associated with attachment, ensuring the infant feels safe and supported.
Choice D rationale
Giving an infant space to allow for natural biological development is a concept that does not apply to the neonatal period. Human infants are born neurologically immature and are biologically programmed to seek out and remain in close proximity to their primary caregiver. Proximity seeking is a survival mechanism. Physical separation can disrupt the development of the internal working model of relationships. Natural development occurs through social interaction and physical touch rather than through physical or emotional distance.
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Rooting is a normal, primitive neonatal reflex where an infant turns their head toward a stimulus on the cheek or mouth. It is an essential developmental sign indicating that the infant is hungry and ready to feed. Because it is a healthy, expected behavioral cue for nourishment, it does not indicate feeding intolerance. Parents should be taught to recognize rooting as a positive sign that the infant is seeking to initiate a feeding session.
Choice B rationale
Spitting up can be a clinical sign of feeding intolerance, especially in high-risk infants who may have gastroesophageal reflux or delayed gastric emptying. While some regurgitation is common, frequent or forceful spitting up can lead to poor weight gain and respiratory complications. It indicates that the infant's digestive system is struggling to process the volume or type of feeding provided, necessitating a thorough evaluation by a healthcare provider to prevent nutritional deficits.
Choice C rationale
Apnea, or the cessation of breathing for 20 seconds or longer, is a critical sign of feeding intolerance in high-risk infants. It often occurs during or after feedings due to vasovagal responses, reflux, or exhaustion. In high-risk neonates, the coordination of sucking, swallowing, and breathing is often immature. Apnea during feeding is a red flag that the infant is not tolerating the physiological demands of the feeding process and requires immediate medical attention.
Choice D rationale
A 30-minute feeding duration is generally considered within the normal range for an infant. It represents a balance where the infant can obtain sufficient nutrition without overexertion. Feeding intolerance would more likely be suggested by an infant who takes much longer due to fatigue or one who finishes too quickly and then vomits. A consistent 30-minute window indicates a functional pace of ingestion and does not typically warrant an immediate emergency report.
Choice E rationale
Sleepiness after a feeding is usually a sign of satiety and comfort, as the metabolic process of digestion and the hormonal release of cholecystokinin promote a relaxed state. While excessive lethargy that prevents feeding is a concern, general sleepiness following a successful meal is a normal physiological response. It does not qualify as a sign of intolerance unless it is accompanied by an inability to wake for subsequent scheduled feeding sessions.
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