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. A score of 7 would be given if the infant’s heart rate was 100, but with less than optimal responses for color, muscle tone, and respiratory effort. However, this baby demonstrates strong responses in all categories.

B. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The infant in the scenario has:

Heart rate of 100 (score 2)

Pink body and blue hands (score 1 for color—because the baby is not fully pink, indicating some cyanosis in the extremities)

Active motion (score 2 for muscle tone)

Strong lusty cry (score 2 for reflex irritability/responsiveness to stimuli)

Good respirations (score 2)

Adding these scores (2 + 1 + 2 + 2 + 2), the total is 8.

C. A score of 5 would indicate more significant distress, with poor color, respiratory effort, and muscle tone. This infant is showing good signs of adaptation.

D. A score of 9 would indicate that the baby has no signs of cyanosis and perfect responses in all categories, but since the infant has blue hands, it scores slightly lower (1 point less for color).

A. Document the finding, as it is a normal finding at this time. B. Contact the primary care provider, as it indicates early DIC. C. Obtain a prescription for a CBC, as it suggests postpartum anemia. D. Contact the primary care provider, as it is a first sign of postpartum eclampsia.

Correct Answer is A

Explanation

A. A pulse rate of 66 beats per minute is within the normal range for a postpartum woman, particularly 12 hours after birth. It's common for the pulse rate to decrease after delivery, as the body stabilizes and returns to its pre-pregnancy state. This is not a cause for concern and can be considered a normal physiological response to the postpartum period.

B. Contact the primary care provider, as it indicates early DIC (disseminated intravascular coagulation). This is unlikely, as DIC typically presents with more severe symptoms, such as bleeding, bruising, and a drop in blood pressure, not a lower pulse rate. A normal or slightly decreased pulse is not indicative of DIC.

C. While it's important to monitor for signs of anemia in the postpartum period (such as fatigue, dizziness, or weakness), a pulse of 66 beats per minute is not a typical sign of anemia. Anemia would more likely be accompanied by other symptoms, such as pallor or weakness.

D. Postpartum eclampsia typically presents with high blood pressure, severe headache, visual disturbances, or seizures, not a low pulse rate. A pulse rate of 66 beats per minute is not a sign of eclampsia.

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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 performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

Correct Answer is B

Explanation

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

Correct Answer is A

Explanation

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