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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The presence of Rh factor in the mother's blood and absence in the newborn’s does not lead to antibody formation targeting fetal red blood cells directly. Rh incompatibility arises when the mother lacks the Rh factor and forms anti-Rh antibodies against the Rh-positive fetal blood. This leads to hemolysis and hyperbilirubinemia in affected newborns.
Choice B rationale
Anti-A and anti-B antibodies are associated with ABO incompatibility, not Rh incompatibility. ABO incompatibility can cause mild hemolysis but does not lead to severe hyperbilirubinemia seen in Rh incompatibility. Rh incompatibility specifically involves anti-Rh antibodies produced by Rh-negative mothers targeting Rh-positive fetal red cells.
Choice C rationale
Receiving a transfusion with Rh-negative blood would not trigger Rh incompatibility. Rh incompatibility is driven by maternal sensitization to Rh-positive fetal blood during pregnancy or delivery, leading to antibody formation and subsequent hemolysis in future Rh-positive pregnancies.
Choice D rationale
When the mother lacks the Rh factor (Rh-negative), she can produce anti-Rh antibodies upon exposure to Rh-positive fetal blood. These antibodies cross the placenta and attack fetal red blood cells, causing hemolysis and hyperbilirubinemia. This process is the hallmark of Rh incompatibility-related pathology.
Correct Answer is B
Explanation
Choice A rationale
A positive rubella serum antibody titer indicates immunity to rubella infection, which is protective during pregnancy. It is not an abnormal finding and does not require immediate reporting. Rubella immunity is important to prevent congenital rubella syndrome in the fetus, a severe condition causing defects such as deafness or cardiac anomalies.
Choice B rationale
Blood pressure of 144/94 mmHg is elevated and indicates gestational hypertension, which could progress to preeclampsia if not managed. Preeclampsia can lead to complications such as eclampsia, placental abruption, or maternal and fetal mortality. Normal blood pressure during pregnancy is less than 140/90 mmHg, making this finding critical to report.
Choice C rationale
Copious leukorrhea is a common physiological change in pregnancy due to increased estrogen levels and vascularity. It is usually benign and protective, preventing infections by maintaining a mildly acidic environment in the vagina. This finding does not warrant immediate concern unless associated with infection symptoms.
Choice D rationale
An O-negative blood type requires administration of Rh immunoglobulin to prevent Rh isoimmunization, but this is routinely managed in pregnancy. It is not an urgent issue unless there are concerns about fetomaternal hemorrhage or alloimmunization, which could harm an Rh-positive fetus.
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