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 B

Explanation

Choice A reason: While nausea, tiredness, and sleepiness are common during the first trimester of pregnancy, they are typically not signs of an immediate emergency. This patient does not exhibit any alarming symptoms that would require immediate hospital referral.

Choice B reason: Blurred vision and seeing spots during pregnancy can be symptoms of preeclampsia, a potentially dangerous condition characterized by high blood pressure. Preeclampsia can pose serious health risks to both the mother and the baby and requires immediate medical attention.

Choice C reason: Frequent urination is a common symptom in the later stages of pregnancy due to the pressure the growing baby exerts on the bladder. This symptom alone does not indicate an immediate need for hospital evaluation.

Choice D reason: Having 4 to 5 contractions in an hour at 37 weeks of pregnancy can be a sign of early labor. However, unless the contractions are persistent and intensifying, this may not necessitate an immediate hospital referral. The nurse would likely advise the patient to monitor the contractions and come in if they continue or become stronger.

A. Lethargy and hypotonia B. Elastic skin turgor C. Apical heart rate = 64 beats per minute D. Blood pressure = 100/54 mmHg E. Flat anterior fontanel

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Lethargy and hypotonia are critical findings in a child who was left in a closed car. These symptoms can indicate severe dehydration, heat stroke, or other serious conditions that require immediate medical attention.

Choice B reason: Elastic skin turgor generally indicates good hydration status and is not an immediate concern that needs to be reported urgently in this context.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a 14-month-old child, indicating bradycardia, which can be a sign of severe heat stress or dehydration. This finding needs immediate reporting.

Choice D reason: A blood pressure of 100/54 mmHg is within the normal range for many paediatric patients, but in the context of being left in a hot car, it can suggest potential complications and should be monitored closely. However, it is not as critical as the heart rate and mental status findings.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention in this context.

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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

The clinic nurse is performing phone triage on pregnant patients. Which patient will the nurse refer to the hospital for immediate evaluation?

Correct Answer is B

Explanation

The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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