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

A slurping or clicking sound as the infant sucks.

Audible swallowing.

Infant's tongue cups under the breast with lips flanged.

The mother can see a rhythmic sucking pattern.

Dimpling of the infant's cheeks while sucking.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

A slurping or clicking sound indicates poor latching and is often associated with air entering the mouth due to improper seal or positioning of the infant. These sounds can reflect nipple misalignment or inadequate breast tissue placement into the infant's mouth, affecting milk transfer and leading to potential breastfeeding complications, such as nipple pain or reduced milk intake.

Choice B rationale

Audible swallowing confirms that the infant is successfully transferring milk and is properly latched. Proper latch allows efficient milk removal, which triggers swallowing reflexes. It reflects an absence of air entry and indicates that the infant is receiving milk without difficulty, promoting both nutritional intake and breastfeeding success.

Choice C rationale

The infant's tongue cupping under the breast with lips flanged ensures proper latch by creating a vacuum seal. This position prevents air leakage and allows effective milk transfer. Tongue cupping and lip flanging optimize compression of the lactiferous sinuses, supporting effective breastfeeding and minimizing discomfort for the mother.

Choice D rationale

Rhythmic sucking is a sign of coordinated latch and feeding. It reflects successful milk transfer and synchronization between suckling and swallowing. Rhythmic patterns reduce the risk of nipple trauma by ensuring proper placement and suction. This indicates that breastfeeding dynamics are efficient and beneficial.

Choice E rationale

Dimpling of the infant's cheeks occurs due to suction difficulties and often signifies improper latch or weak oral musculature. It leads to air leakage and insufficient milk removal. This finding may contribute to feeding inefficiencies and nipple trauma, indicating a need for latch correction.

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Correct Answer is C

Explanation

Choice A rationale

Removing a pacifier does not align with preventing SIDS. Studies suggest pacifier use during sleep reduces the risk of SIDS by maintaining airway patency and ensuring better sleep quality, though it should be used appropriately without attaching strings or clips that may pose risks.

Choice B rationale

Feeding every 2 hours does not directly prevent SIDS but supports adequate nutrition for growth and development. While proper feeding schedules are important, specific sleeping arrangements and environment management play a more significant role in reducing SIDS risk.

Choice C rationale

Placing the newborn on their back to sleep aligns with safe sleep recommendations to prevent SIDS. This position reduces the risk of airway obstruction and promotes proper breathing. The supine sleep position is widely endorsed by health organizations for its protective effect.

Choice D rationale

Draping a blanket over the newborn increases the risk of suffocation and overheating, both of which are associated with SIDS. It is essential to keep sleep environments free of loose items and ensure the baby is dressed appropriately for the room's temperature to reduce these risks.

A. Keep the newborn in a well-lit nursery. B. Cluster the newborn's care activities. C. Use fingertips when calming the newborn. D. Position the newborn to promote extension of muscles.

Correct Answer is B

Explanation

Choice A rationale

Keeping the newborn in a well-lit nursery may interfere with their ability to develop circadian rhythms, which are critical for growth and development. Premature newborns are particularly sensitive to environmental stress, and excessive lighting can disrupt their sleep-wake cycle, increasing stress and affecting neurological development.

Choice B rationale

Clustering care activities minimizes disruptions and allows the newborn to have longer periods of rest. This approach is vital for preterm infants, as uninterrupted sleep enhances brain growth, reduces energy expenditure, and promotes physiological stability, such as maintaining appropriate heart and respiratory rates.

Choice C rationale

Using fingertips when calming the newborn may not provide the soothing effects of a whole-hand approach. Gentle hand placement offers a more consistent pressure that mimics the containment provided in the womb, aiding in neuromuscular development and decreasing stress in preterm infants.

Choice D rationale

Positioning the newborn to promote muscle extension opposes the fetal position they naturally adopt and disrupts their physiological flexion posture. This posture facilitates stability and self-regulation and supports motor development, which is essential for preterm infants adjusting to life outside the womb.

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

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