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 D

Explanation

A. Deficient fluid volume is not the priority concern at this time. While newborns are at risk for dehydration, there are no indications in the assessment (such as dry mucous membranes or poor feeding) that would suggest deficient fluid volume as the immediate priority.

B. Risk for infection is a concern for all newborns, especially in the first hours of life. However, the information provided does not suggest signs of infection such as fever, lethargy, or abnormal skin color.

C. Impaired parenting may be a concern later on if the parents show difficulty bonding or caring for the infant. However, this is not the immediate priority based on the infant's current assessment.

D. Hypothermia is the priority. The infant’s axillary temperature of 95.8° F (35.4° C) is below the normal range for a newborn, which is typically between 97.7° F (36.5° C) and 99.5° F (37.5° C). Hypothermia in newborns can lead to complications such as respiratory distress, metabolic instability, and increased risk for infection. Immediate interventions, such as warming the infant and ensuring a warm environment, are necessary to prevent further complications.

A. normal progression of behavior. B. probable hypoglycemia. C. physiological abnormality. D. inadequate oxygenation.

Correct Answer is A

Explanation

A. Newborns typically go through predictable behavioral states after birth. During the first period of reactivity, which lasts about 30–60 minutes after birth, the newborn is awake, alert, and active. This is followed by a period of sleep or decreased activity, which can last 2 to 4 hours. It is normal for the baby to be sleepy and difficult to awaken during this phase, especially around 2 hours of age.

B. Probable hypoglycemia could cause lethargy in a newborn, but it would typically be accompanied by other symptoms such as jitteriness, poor feeding, or abnormal vital signs. In a healthy 2-hour-old baby, sleepiness alone is not enough to suggest hypoglycemia.

C. Physiological abnormality is incorrect. There is no evidence of abnormality in a sleepy 2-hour-old newborn, as this is an expected part of the normal behavioral cycle after birth.

D. Inadequate oxygenation would likely present with signs such as cyanosis, abnormal respiratory rate, or poor perfusion, not just sleepiness.

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

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Naxlex Comprehensive Predictor Exams

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

Correct Answer is D

Explanation

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

Correct Answer is A

Explanation

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