Which three (3) assessment findings indicate that the breastfeeding client has achieved a proper latch?

Rhythmic suckling

A slurping sound as the infant sucks

Tongue down with lips flanged

Dimpling of the infant's cheeks while sucking

Audible swallowing

Answer and Explanation

Correct Answer : A,C,E

A. Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing. Indicates milk transfer is occurring as the infant swallows.

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Correct Answer is ["C","D"]

Explanation

Answer: C, D

A. Hypertonia
Hypertonia, or increased muscle tone, is not a common characteristic of Trisomy 21. In fact, many infants with Down's Syndrome typically exhibit hypotonia, or decreased muscle tone, which can affect their overall strength and development.

B. Large ears
While individuals with Down's Syndrome may have unique ear shapes, "large ears" are not specifically characteristic of Trisomy 21. Instead, the ears may appear small or have a different shape compared to those of typically developing children.

C. Transverse palmar creases
Transverse palmar creases, also known as simian lines, are commonly seen in individuals with Down's Syndrome. This feature is a characteristic finding that can help in identifying the condition during physical assessment.

D. Protruding tongue
A protruding tongue is a common feature in individuals with Down's Syndrome. This occurs due to hypotonia of the oral muscles, which can lead to difficulties in tongue control and positioning.

E. Low birth weight
Low birth weight is not a defining characteristic of Trisomy 21. In fact, newborns with Down's Syndrome can have varying birth weights; they are often average weight or slightly above average, although some may be below average due to other factors related to maternal health or gestational issues.

A. Encourage the client to empty her bladder. B. Notify the client's provider. C. Increase the frequency of fundal massage. D. Document the findings and continue to monitor the client.

Correct Answer is D

Explanation

A. Encourage the client to empty her bladder. This might help if the fundus were not midline, but since it is firm and midline, it’s not necessary.
B. Notify the client's provider. Immediate notification is not required for these findings as they are within the expected range postpartum.
C. Increase the frequency of fundal massage. Frequent fundal massage is not necessary since the fundus is already firm.
D. Document the findings and continue to monitor the client. A firm fundus with moderate bleeding and small clots can be normal in the immediate postpartum period. The nurse should document these findings and continue to monitor.

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Which three (3) assessment findings indicate that the breastfeeding client has achieved a proper latch?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select All that Apply.)

Correct Answer is ["C","D"]

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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