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 A

Explanation

A. Ice helps to reduce swelling, numb the area, and relieve pain during the first 24 hours after an episiotomy. Applying ice immediately after birth can help minimize discomfort and inflammation.

B. Offer warm blankets may provide comfort but will not specifically target pain relief or swelling at the site of the episiotomy.

C. Offer a warm sitz bath is beneficial for postpartum healing and pain relief but should not be used immediately after the procedure. Warm sitz baths are typically recommended after the first 24 hours to promote relaxation and improve blood circulation.

D. Encourage the woman to void is important for overall comfort and bladder function but will not directly address the pain from the episiotomy.

A. Weight gain and shortness of breath B. Epigastric pain and elevated liver enzymes C. Edema of hands and feet of +2 D. Fatigue and headache

Correct Answer is B

Explanation

A. Weight gain and shortness of breath are common symptoms of pre-eclampsia or hypertension, but they are not specific to HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets). Shortness of breath could be due to other conditions, such as pulmonary edema, but it does not directly indicate HELLP syndrome.

B. Epigastric pain and elevated liver enzymes is a classic symptom of HELLP syndrome, a severe form of pregnancy-induced hypertension (PIH). The epigastric pain is often related to liver distention due to the liver damage and elevated liver enzymes. This is a key indicator of HELLP syndrome, which can be life-threatening if not managed promptly.

C. Edema of hands and feet of +2 is a common finding in pregnancy-related hypertension or pre-eclampsia but is not specific to HELLP syndrome. Mild edema (such as +2) can occur in many pregnancies and does not necessarily indicate the severity of the condition.

D. Fatigue and headache are symptoms commonly seen in pre-eclampsia and may also occur in HELLP syndrome, but they are less specific compared to epigastric pain and elevated liver enzymes, which are hallmark signs of HELLP syndrome.

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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

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

Correct Answer is A

Explanation

The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

Correct Answer is B

Explanation

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply.

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?