A nurse is caring for a client who is breastfeeding and states that her nipples are sore and cracking. Which of the following actions should the nurse take?
Assess and ensure the newborn has a successful latch.
Recommend increasing the length of time between feedings.
Educate the client to apply mineral oil to the nipples between feedings.
Educate the client to keep the nipples covered between breastfeeding sessions.
The Correct Answer is A
Choice A rationale
Ensuring the newborn has a successful latch is crucial for preventing and treating sore and cracked nipples. A poor latch can cause nipple trauma and pain.
Choice B rationale
Increasing the length of time between feedings is not recommended as it can lead to engorgement and further complications. Frequent breastfeeding helps maintain milk supply and prevents issues like mastitis.
Choice C rationale
Applying mineral oil to the nipples is not recommended. Instead, using expressed breast milk or medical-grade lanolin can promote healing.
Choice D rationale
Keeping the nipples covered between breastfeeding sessions is not necessary and can sometimes exacerbate the problem. Allowing the nipples to air dry or using hydrogel pads can be more beneficial.
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Correct Answer is B
Explanation
Choice A rationale
Teaching the parents how to swaddle is important for newborn care, but it is not the priority action immediately after delivery to promote parent-infant bonding. Skin-to-skin contact is more effective in establishing an initial bond.
Choice B rationale
Positioning the infant on the client’s chest for skin-to-skin care is the priority action to promote parent-infant bonding immediately after delivery. Skin-to-skin contact helps regulate the infant’s temperature, heart rate, and breathing, and promotes bonding through physical closeness and sensory interaction.
Choice C rationale
Offering to take the newborn to the nursery so the parents may nap is not the priority action for promoting bonding immediately after delivery. While rest is important, the initial moments after birth are crucial for establishing a bond through direct contact.
Choice D rationale
Assessing the infant under the radiant warmer is important for ensuring the infant’s health, but it is not the priority action for promoting parent-infant bonding immediately after delivery. Skin-to-skin contact should be prioritized unless there are medical concerns that require immediate attention. .
Correct Answer is C
Explanation
Choice A rationale
A temperature of 99.0°F (37.3°C) is within the normal range and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice B rationale
A respiratory rate of 18/min is within the normal range for adults and is not specifically associated with cardiovascular system changes in the postpartum period. It is a common finding and does not indicate any specific cardiovascular changes.
Choice C rationale
An elevated white blood cell (WBC) count of 22,000/mm³ is a common finding in the postpartum period due to the body’s response to the stress of childbirth. This leukocytosis is a normal physiological response and is associated with the cardiovascular system changes during this period.
Choice D rationale
Urinary retention is not specifically associated with cardiovascular system changes in the postpartum period. It can occur due to various reasons, including the effects of anesthesia or trauma during delivery, but it is not a direct result of cardiovascular changes.