The nurse is caring for a newborn born at 30 weeks' gestation.
Which assessment finding should the nurse anticipate?

Choice A rationale

Diaphragms need to be refitted periodically as changes in weight, pregnancy, or aging can affect their fit. This ensures that the device continues to function effectively by providing a proper seal over the cervix, reducing the risk of unintended pregnancy. Therefore, the statement about the diaphragm always being the correct size is inaccurate as it does not consider these physiological factors.

Choice B rationale

Diaphragms are not recommended for use during menstruation because the menstrual flow can compromise their efficacy and hygiene. Additionally, the risk of toxic shock syndrome may increase if the device is used during menstruation. This is a critical point to emphasize for the safe and effective use of diaphragms in contraception.

Choice C rationale

Leaving the diaphragm in place for six hours after intercourse ensures that sperm are effectively trapped and neutralized by the spermicide used with the device. This is essential for preventing fertilization and optimizing contraceptive effectiveness. The timing is critical to allow the spermicide to work while the diaphragm acts as a physical barrier.

Choice D rationale

Leaving the diaphragm in for extended periods beyond six hours is not recommended due to the increased risk of infection and toxic shock syndrome. The device should be removed within a safe timeframe to maintain hygiene and reduce health risks, making the statement about leaving it for a day or two incorrect.

Choice A rationale

A slurping or clicking sound indicates poor latching and is often associated with air entering the mouth due to improper seal or positioning of the infant. These sounds can reflect nipple misalignment or inadequate breast tissue placement into the infant's mouth, affecting milk transfer and leading to potential breastfeeding complications, such as nipple pain or reduced milk intake.

Choice B rationale

Audible swallowing confirms that the infant is successfully transferring milk and is properly latched. Proper latch allows efficient milk removal, which triggers swallowing reflexes. It reflects an absence of air entry and indicates that the infant is receiving milk without difficulty, promoting both nutritional intake and breastfeeding success.

Choice C rationale

The infant's tongue cupping under the breast with lips flanged ensures proper latch by creating a vacuum seal. This position prevents air leakage and allows effective milk transfer. Tongue cupping and lip flanging optimize compression of the lactiferous sinuses, supporting effective breastfeeding and minimizing discomfort for the mother.

Choice D rationale

Rhythmic sucking is a sign of coordinated latch and feeding. It reflects successful milk transfer and synchronization between suckling and swallowing. Rhythmic patterns reduce the risk of nipple trauma by ensuring proper placement and suction. This indicates that breastfeeding dynamics are efficient and beneficial.

Choice E rationale

Dimpling of the infant's cheeks occurs due to suction difficulties and often signifies improper latch or weak oral musculature. It leads to air leakage and insufficient milk removal. This finding may contribute to feeding inefficiencies and nipple trauma, indicating a need for latch correction.