Which statement made by the lactating woman would lead the nurse to believe that the woman might have lactose intolerance?

"Sometimes I notice that I have bad breath after I drink a cup of milk.”.

"If I drink more than a cup of milk, I usually have abdominal cramps and bloating.”.

"Drinking milk usually makes me break out in hives.”.

"I always have heartburn after I drink milk.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Halitosis or bad breath is not a diagnostic indicator of lactose intolerance. While oral bacteria can interact with various food particles, the primary scientific mechanism of lactose intolerance involves the inability of the small intestine to produce sufficient lactase. This enzyme is required to break down lactose into glucose and galactose. Without it, undigested sugars pass into the colon, leading to gastrointestinal distress rather than isolated changes in breath odor or oral hygiene.

Choice B rationale

Lactose intolerance occurs when the body lacks lactase, the enzyme needed to digest milk sugar. When a person consumes more milk than their enzyme levels can handle, undigested lactose enters the large intestine. Bacteria ferment this sugar, creating hydrogen gas and lactic acid. This process results in the classic clinical presentation of abdominal cramping, bloating, and flatulence. Symptoms typically appear within 30 to 60 minutes after ingestion of dairy products containing lactose.

Choice C rationale

Hives or urticaria are manifestations of a Type I hypersensitivity reaction, which is an immune system response to milk proteins like casein or whey. This represents a true milk allergy rather than an enzymatic deficiency. In lactose intolerance, the immune system is not involved, and the reaction is strictly metabolic and gastrointestinal. Normal physiological responses to intolerance do not include the release of histamine or the formation of itchy wheals on the skin surface.

Choice D rationale

Heartburn or pyrosis is caused by the reflux of gastric acid into the esophagus, often due to a relaxed lower esophageal sphincter. While some dairy products are high in fat and can slow gastric emptying, heartburn is not the hallmark of lactose intolerance. The fermentation of lactose happens in the lower gastrointestinal tract, specifically the colon, whereas heartburn is an upper gastrointestinal issue. Therefore, this symptom points toward gastroesophageal reflux disease rather than lactase deficiency.

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Correct Answer is D

Explanation

Choice A rationale

Hypoxia in a fetus is often indicated by late decelerations, loss of variability, or persistent tachycardia or bradycardia. A fetal heart rate of 135 beats/min is a stable and reassuring finding that suggests adequate oxygenation and a functional autonomic nervous system. Hypoxia would typically trigger a physiological stress response that moves the heart rate outside of the normal established baseline. Therefore, 135 beats/min does not meet the clinical criteria for documenting fetal oxygen deprivation.

Choice B rationale

Bradycardia in a fetus is defined as a baseline heart rate of less than 110 beats/min for a duration of at least 10 minutes. Since the nurse recorded an average rate of 135 beats/min over a 10-minute period, the fetus is well above the threshold for bradycardia. Fetal bradycardia can be caused by cord compression, maternal hypotension, or fetal cardiac defects. The recorded rate is perfectly mid-range and does not indicate any slow heart rate concerns.

Choice C rationale

Tachycardia in a fetus is defined as a baseline heart rate of greater than 160 beats/min for a duration of 10 minutes or more. It can be caused by maternal fever, fetal infection, or maternal dehydration. A heart rate of 135 beats/min is significantly lower than the tachycardic threshold. Because the rate falls within the expected window, it would be incorrect to document this as tachycardia. The rate indicates a stable fetal status without excessive sympathetic stimulation.

Choice D rationale

A normal fetal heart rate baseline ranges from 110 to 160 beats/min. An average rate of 135 beats/min over a 10-minute period falls directly within this expected normal range. This finding is considered reassuring and indicates that the fetus is currently compensating well for the stress of labor. Documentation should reflect that this is a normal baseline, as it shows the fetal heart is beating at an appropriate frequency to maintain systemic perfusion and oxygenation.

A. Running warm water on her breasts during a shower. B. Applying ice to the breasts for comfort. C. Wearing a loose-fitting bra to prevent nipple irritation. D. Expressing a small amount of milk from the breasts to relieve pressure.

Correct Answer is B

Explanation

Choice B rationale

For a woman who is bottle-feeding, the goal is to suppress lactation and reduce the discomfort of engorgement. Applying ice packs to the breasts causes vasoconstriction and reduces the metabolic activity of the milk-producing cells. This helps decrease swelling, warmth, and pain. Cold therapy should be applied for about 15 to 20 minutes several times a day. Unlike heat, cold does not stimulate further milk production, making it the preferred choice for non-breastfeeding mothers.

Choice A rationale

Running warm water on the breasts during a shower is a technique used to stimulate milk let-down and promote flow. For a woman who has decided to bottle-feed, this is contraindicated as it encourages continued lactation and can worsen the pressure and pain of engorgement. Heat causes vasodilation and increases blood flow to the mammary glands, which would exacerbate the symptoms the patient is currently experiencing. She should avoid all forms of heat and nipple stimulation.

Choice C rationale

While a supportive bra is recommended, it should be well-fitting and firm rather than loose. A loose-fitting bra allows the breasts to move, which can cause friction and discomfort. A tight, supportive bra provides compression that helps suppress milk production and reduces the heavy feeling associated with engorgement. It also prevents the stimulation of the nipples by the fabric, which could otherwise trigger the release of prolactin and oxytocin, leading to further milk synthesis.

Choice D rationale

Expressing milk, even in small amounts, provides temporary relief from pressure but ultimately signals the body to produce more milk. This is based on the principle of supply and demand. For a mother choosing to bottle-feed, any removal of milk will prolong the lactation process and delay the natural involution of the mammary glands. To stop milk production, the breasts must remain full so that the feedback inhibitor of lactation can build up and stop synthesis.

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Which statement made by the lactating woman would lead the nurse to believe that the woman might have lactose intolerance?

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Naxlex Comprehensive Predictor Exams

A nurse assessed a fetus with an average heart rate of 135 beats/min over a 10-minute period during labor. The nurse would document this observation to be:

Correct Answer is D

Explanation

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During the assessment, the nurse noticed that both of her breasts were swollen, warm, and tender on palpation. The nurse advised the woman that this situation can best be treated by.

Correct Answer is B

Explanation

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