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 B
Explanation
Choice A rationale
Thanking the nurse for information does not provide an actionable or measurable response to the safety plan. It signifies acknowledgment but does not demonstrate engagement or utilization of the resources provided. Effective evaluation involves observable actions that reflect the client's commitment to safety measures, such as storing or sharing resources.
Choice B rationale
Storing the crisis center number in their phone indicates the client values the provided resource and anticipates using it if necessary. It shows a proactive step in engaging with the safety plan and retaining information for future use. This measurable action demonstrates their awareness of the importance of having immediate access to help during emergencies.
Choice C rationale
The belief that their home will become safer due to the presence of a baby reflects denial or false optimism. It fails to address the inherent risks of intimate partner violence, which often escalate during stressful situations. A rational evaluation involves recognizing danger and taking steps to access resources for safety.
Choice D rationale
Choosing not to leave their home indicates resistance or inability to engage with the safety plan effectively. It reflects a lack of readiness to act on safety measures, making this response inappropriate as a measure of evaluating the safety plan. Behavioral change is necessary to ensure the client's well-being.
Correct Answer is B
Explanation
B. Slight yellow vaginal discharge is correct.This is a classic symptom of gonorrhea in females. Gonorrhea often causes mucopurulent cervicitis, leading to a mild yellow vaginal discharge. It’s one of the most common signs, especially in sexually active adolescents.
Incorrect options:
-
A. Low-grade fever for three days:
Not a typical early symptom of gonorrhea. Fever may occur in severe or disseminated gonococcal infections, but it's uncommon as an initial presentation. -
C. Frothy, white vaginal discharge:
This is more characteristic of trichomoniasis, another STI, caused by Trichomonas vaginalis. The discharge is typically frothy, greenish-yellow, and accompanied by a foul odor. -
D. Decrease in urinary frequency:
Not associated with gonorrhea. Gonorrhea can cause increased urinary frequency and urgency if the urethra is involved, but a decrease is not typical.
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