Which action by the nurse is most effective to prevent sore nipples in a breastfeeding client?

Limit the amount of time the infant nurses on each breast

Apply nipple shields when not breastfeeding the infant

Instruct client to apply lanolin-based product to nipples

Ensure that the client positions and latches the infant correctly on the breast

Answer and Explanation

The Correct Answer is D

A. Limit the amount of time the infant nurses on each breast is not an effective strategy for preventing sore nipples. The issue is usually related to poor latch or positioning, not the duration of breastfeeding. Limiting nursing time could negatively impact milk supply and bonding.

B. Apply nipple shields when not breastfeeding the infant is not typically recommended as a preventive measure for sore nipples. Nipple shields are more often used to assist with latching problems, not to prevent soreness. Prolonged use can sometimes contribute to nipple confusion and further complications.

C. Instruct client to apply lanolin-based product to nipples can provide temporary relief for sore or cracked nipples, but it does not prevent soreness. The root cause of nipple pain is often related to improper positioning and latch, so this is more of a remedy than a preventive measure.

D. Ensure that the client positions and latches the infant correctly on the breast is the most effective way to prevent sore nipples. A proper latch ensures that the infant is effectively removing milk and reduces the likelihood of nipple trauma. The nurse should help the client with correct positioning, ensuring that the infant's mouth covers a large portion of the areola, not just the nipple.

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Correct Answer is B

Explanation

A. 50mg/hr is not the correct unit for volume, it’s the dose in milligrams.
B. 50 mL/hr is the correct volume to administer to achieve the ordered dose of 2g/hr. Determine the concentration of the solution: The supply is 10g in 250mL. This means the concentration is 10g / 250mL, or 0.04g/mL (since 10g = 10,000mg, this is equivalent to 40mg/mL). Convert the ordered dose to match the concentration: The order is for 2g/hr (which is 2,000mg/hr). Calculate the volume to be infused to deliver the desired dose: Dose = Ordered/concentration= 2000/40= 50 mL/hr
C. 5mg/mL refers to the concentration, not the rate of infusion.
D. 5 mL/hr would administer only 200mg/hr, which is much lower than the ordered dose of 2g/hr.

A. Polyhydramnios B. Placenta previa C. Placental abruption D. Ruptured ectopic pregnancy

Correct Answer is B

Explanation

A. Polyhydramnios refers to an excessive amount of amniotic fluid and typically presents with maternal discomfort, dyspnea, and possibly preterm labor, but not with vaginal bleeding as a primary symptom.

B. Placenta previa is the most likely diagnosis based on the assessment findings. It typically presents with painless, bright red vaginal bleeding in the second or third trimester, a soft, nontender uterus, no contractions, and a normal fetal heart rate. The bleeding may start spontaneously and often recurs. This fits the client's clinical picture precisely.

C. Placental abruption usually involves painful vaginal bleeding, a firm or tender uterus, and may be associated with uterine contractions or abnormal fetal heart rate patterns. The absence of pain and uterine tenderness in this case makes placental abruption less likely.

D. Ruptured ectopic pregnancy would not be expected at 33 weeks’ gestation. Ectopic pregnancies typically present in the first trimester and are accompanied by severe abdominal pain, vaginal bleeding, and signs of hypovolemic shock if ruptured.

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Which action by the nurse is most effective to prevent sore nipples in a breastfeeding client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is being treated with Magnesium Sulphate. Ordered 2g/hr Supplied 10g/250ml bag What would be the correct calculations for the maintenance dose in ml/hr

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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