The nurse is caring for a patient who is two days postpartum and exclusively breastfeeding. Upon assessment, the patient has cracked nipples and a painful latch. What will the nurse include in the patient's plan of care?

Begin formula supplementation

Cleanse the breast with soap and water

Reposition the baby

Administer ibuprofen

Answer and Explanation

The Correct Answer is C

Choice A reason: Beginning formula supplementation is not the first step in addressing issues with breastfeeding. Introducing formula might reduce the infant’s breastfeeding efficiency and disrupt milk supply. The focus should initially be on correcting the breastfeeding technique to ensure successful and comfortable breastfeeding for both mother and baby.

Choice B reason: Cleansing the breast with soap and water is not recommended as it can dry out the nipples and exacerbate cracking. It is more appropriate to clean the breasts with warm water and avoid harsh soaps that could strip natural oils and worsen nipple damage.

Choice C reason: Repositioning the baby is a crucial step in addressing breastfeeding issues such as cracked nipples and a painful latch. Ensuring a proper latch can significantly reduce nipple trauma and improve comfort during breastfeeding. Techniques like ensuring the baby’s mouth covers more areola and changing breastfeeding positions can help achieve a better latch.

Choice D reason: Administering ibuprofen may help relieve pain temporarily, but it does not address the root cause of the breastfeeding issue. The primary focus should be on correcting the baby's latch and positioning to prevent ongoing nipple damage and pain during breastfeeding. Pain management should be considered alongside addressing the underlying problems.

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Correct Answer is C

Explanation

Choice A reason: Waiting until the urge to push before going to the hospital is not advisable. If the water has broken, it indicates that Labor may be starting, and the pregnant person should be evaluated to ensure the safety of both the parent and the baby.

Choice B reason: Waiting for contractions to start before calling back is not recommended. If the water has broken, there is a risk of infection and other complications, so immediate evaluation is necessary.

Choice C reason: Coming to the Labor and delivery unit for an evaluation is the correct response. When the water breaks, it is important to assess the mother and baby to determine the next steps and ensure that both are healthy and safe.

Choice D reason: Drinking water and lying down is not an appropriate response to the water breaking. While staying hydrated is important during pregnancy, the priority should be to seek immediate medical evaluation.

Correct Answer is ["1"]

Explanation

The APGAR score assesses five criteria: Appearance (skin colour), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0 to 2, with a maximum total score of 10.

Appearance: The infant is pale, which scores 0.
Pulse: The heart rate is 99 beats per minute, which scores 1 (as it is below 100).
Grimace: No response to stimulus, which scores 0.
Activity: The infant is limp, which scores 0.
Respiration: No spontaneous respirations, which scores 0.

Summing these scores gives a total APGAR score of 1.

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The nurse is caring for a patient who is two days postpartum and exclusively breastfeeding. Upon assessment, the patient has cracked nipples and a painful latch. What will the nurse include in the patient's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pregnant person telephones the prenatal clinic and reports that their "water just broke." How will the nurse respond?

Correct Answer is C

Explanation

The nurse is caring for an infant delivered one minute ago. The infant has no spontaneous respirations, no response to stimulus, is limp, pale, and has a heart rate of 99 beats per minute. How will the nurse document this infant's APGAR Score? Enter number only (no units).

Correct Answer is ["1"]

Explanation

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