OB Lippincott Postpartal Care - The Postpartal Client Who Breast-Feeds

67. Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? 1. "Wait until you have breast-fed for at least 4 months." 2. "Eliminate the baby's favorite feeding times first." 3. "Plan to omit the daytime feedings last." 4. "Gradually eliminate one feeding at a time."

4. "Gradually eliminate one feeding at a time." The client should wean the infant gradually, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the mother desires; she does not have to breast-feed for 4 months. Most infants (and mothers) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy.

48. The nurse is caring for a primipara who gave birth yesterday and has chosen to breast-feed her neonate. Which assessment finding is considered unusual for the client at this point postpartum? 1. Milk production. 2. Diaphoresis. 3. Constipation. 4. Diuresis.

1. Milk production. New mothers usually begin to produce milk at about the third day postpartum and colostrum is produced until that time. For clients who have breast-fed another infant during pregnancy, having milk shortly after birth is not unusual. Diaphoresis and diuresis are considered normal during this time as the body excretes the additional fluids that are no longer needed after the pregnancy. Constipation may continue for several days as a result of progesterone remaining in the system, the consummation of iron, and trauma to the perineum.

71. The triage nurse in the pediatrician's office returns a call to a mother who is breast-feeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? 1. This type of stool indicates the infant may have diarrhea and should be seen in the office today. 2. The stool will transition into a soft brown formed stool within a few days and is appropriate for breast-feeding. 3. The stool results from the gassy food eaten by the mother. Instruct the mother to refrain from eating these foods while breastfeeding. 4. Soft seedy unformed stools with each feeding are normal for this age infant and will continue through breast-feeding.

4. Soft seedy unformed stools with each feeding are normal for this age infant and will continue through breast-feeding. A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breast-feeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle-fed or after the breast-feeding infant has begun eating food.

68. Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she's crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which of the following? 1. Lack of adequate intake to meet maternal nutritional needs. 2. The mother's fears about the baby's weight gain. 3. Preventing the neonate from sucking long enough with each feeding. 4. The neonate's temporary growth spurt, which requires more feedings.

4. The neonate's temporary growth spurt, which requires more feedings. Neonates normally increase breast-feeding during periods of rapid growth (growth spurts). These can be expected at age 10 to 14 days, 5 to 6 weeks, 2.5 to 3 months, and 4.5 to 6 months. Each growth spurt is usually followed by a regular feeding pattern. Lack of adequate intake to meet maternal nutritional needs is not associated with the neonate's desire for more frequent breast-feeding sessions. However, an intake of adequate calories is necessary to produce quality breast milk. The mother's fears about weight gain and preventing the neonate from sucking long enough are not associated with the desire for more frequent breast-feeding sessions.

66. A breast-feeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake? 1. Six to eight wet diapers by the fifth day. 2. Three to four transitional stools on the fourth day. 3. Ability to fall asleep easily after feeding on the first day. 4. Regain of lost birth weight by the third day.

1. Six to eight wet diapers by the fifth day. The nurse should instruct the client that the baby is getting enough to eat when there are six to eight wet diapers by the fifth day of age. Other signs include good suckling sounds during feeding, dripping breast milk at the mouth, and quiet rest or sleep after the feeding. By the fourth day of age, the infant should have soft yellow stools, not transitional (greenish) stools. Falling asleep easily after feeding on the first day is not a good indicator because most infants are sleepy during the first 24 hours. Most infants regain their lost birth weight in 7 to 10 days after birth. An infant who has gained weight during the first well-baby checkup (usually at 2 weeks) is getting sufficient breast milk at feedings.

52. A 1-day-old breast-fed infant has a bilirubin level that is at an intermediate risk for jaundice. Which statement by the infant's mother indicates an understanding of the teaching regarding jaundice? 1. I should breast-feed my baby as often as possible. 2. I should supplement with formula after every feeding. 3. I should discontinue breast-feeding and change to formula feeding. 4. I should place my baby in direct sunlight several times a day.

1. I should breast-feed my baby as often as possible. Jaundice in a breast-feeding infant is common and is not pathological. Mothers should be taught to breast-feed as often as possible, at least every 2 to 3 hours and until the infant is satiated. Breast-fed babies rarely need to be supplemented with formula. Mothers should be encouraged to continue breast-feeding their infants due to the numerous benefits it provides. Infants should never be placed in direct sunlight.

70. A new father indicates he feels left out of the new family relationship since he is not able to bond the same way as the breastfeeding mother. What is the most appropriate response by the nurse? 1. This is normal and these feelings will go away within a few days. 2. Holding, talking to, and playing with the infant will facilitate bonding between baby and Dad. 3. Bonding occurs later in the first year of life and Dad can become involved when the infant is better able to recognize him. 4. Maternal infant bonding takes priority over paternal infant bonding.

2. Holding, talking to, and playing with the infant will facilitate bonding between baby and Dad. Time for bonding with their newborns is a frequent concern for fathers of breastfed babies. It is common for fathers to express concern about having less intimate contact time. These feelings are normal, but they do not go away in a few days. The father of the baby has to dedicate time to spend with the infant where he can talk to, hold, cuddle, and/or play with the infant. These strategies provide the infant with the contact and stimulation to establish a close bond between them. Bonding occurs from the moment of birth and continues in various ways between mother, father, and infant. Infants recognize and respond to touch, light, and voice immediately after birth. Bonding between both parents is equally important and one does not take priority over the other.

61. A 25-year-old primiparous client who gave birth 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? 1. Keeping plastic liners in the brassiere to keep the nipple drier. 2. Placing as much of the areola as possible into the baby's mouth. 3. Smoothly pulling the nipple out of the mouth after 10 minutes. 4. Removing any remaining milk left on the nipple with a soft washcloth.

2. Placing as much of the areola as possible into the baby's mouth. Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from getting the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off, because the milk has healing properties.

69. During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do? 1. Wipe off any lanolin creams from the nipple before each feeding. 2. Position the baby with the entire areola in the baby's mouth. 3. Feed the baby less often for the next several days. 4. Use a mild soap while in the shower to prevent an infection.

2. Position the baby with the entire areola in the baby's mouth. Even if the nipples are sore and cracked, the mother should position the baby with the entire areola in the baby's mouth so that the nipple is not compressed between the baby's gums during feeding. The best method is to prevent cracked nipples before they occur. This can be done by feeding frequently and using proper positioning. Warm, moist tea bags can soothe cracked nipples because of tannic acid in the tea. Creams on the nipples should be avoided; wiping off any lanolin creams from the nipple before each feeding can cause further soreness. Feeding the baby less often for the next few days will cause engorgement (and possible neonatal weight loss), leading to additional problems. Soap use while in the shower should be avoided to prevent drying and removal of protective oils.

50. A breast-feeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client has a warm, red, painful breast; a temperature of 100°F (37.7°C) and flulike symptoms. What should the nurse do? 1. Encourage the client to breast-feed her infant using the unaffected breast. 2. Refer the woman to her primary health care provider. 3. Inform the client that she needs to discontinue breast-feeding. 4. Instruct the woman to apply warm compresses to the affected breast.

2. Refer the woman to her primary health care provider. The client is exhibiting signs and symptoms of a breast infection (mastitis). The nurse should instruct her to contact her health care provider, who will likely prescribe a prescription for antibiotics. She should continue to breast-feed the infant from both breasts. Frequent breast-feeding is encouraged rather than discontinuing the process for anyone having a breast infection. Applying warm compresses may relieve pain. However, the underlying infection indicated by the elevated temperature indicates that additional treatment with antibiotics will be needed.

56. A breast-feeding primiparous client with a midline episiotomy is prescribed ibuprofen (Motrin) 200 mg orally. The nurse instructs the client to take the medication: 1. Before going to bed. 2. Midway between feedings. 3. Immediately after a feeding. 4. When providing supplemental formula.

3. Immediately after a feeding. Taking ibuprofen 200 mg orally immediately after breast-feeding helps minimize the neonate's exposure to the drug because drugs are most highly concentrated in the body soon after they are taken. Most mothers breast-feed on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decreased by the next breast-feeding session. Taking the medication before going to bed is inappropriate because, although the mother may go to bed at a certain time, the neonate may wish to breast-feed soon after the mother goes to bed. If the mother takes the medication midway between feedings, then its peak action may occur midway between feedings. Breast milk is sufficient for the neonate's nutritional needs. Most breast-feeding mothers should not be encouraged to provide supplemental feedings to the infant because this may result in nipple confusion.

55. Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding? 1. Breast milk quality and richness are decreased. 2. The mother's motivation to breast-feed is diminished. 3. Medications may be excreted in breast milk to the nursing neonate. 4. Medications interfere with the mother's let-down reflex.

3. Medications may be excreted in breast milk to the nursing neonate. Various medications can be excreted in the breast milk and affect the nursing neonate. The client should avoid all nonprescribed medications (such as acetaminophen) unless approved by the primary care provider. Medications typically do not affect the quality of the mother's breast milk. Medications usually do not interfere with or diminish the mother's motivation to breast-feed, nor do they interfere with the mother's let-down reflex.

53. During a home visit, a breast-feeding client asks the nurse what contraception method she and her husband should use until she has her 6-week postpartal examination. Which of the following would be most appropriate for the nurse to suggest? 1. Condom with spermicide. 2. Oral contraceptives. 3. Rhythm method. 4. Abstinence.

1. Condom with spermicide. If not contraindicated for moral, cultural, or religious reasons, a condom with spermicide is commonly recommended for contraception after birth until the client's 6-week postpartal examination. This method has no effect on the neonate who is breast-feeding. Oral contraceptives containing estrogen are not advised for women who are breast-feeding because the hormones decrease the production of breast milk. Women who are not breast-feeding may use oral contraceptive agents. The rhythm method is not effective because the client is unlikely to be able to determine when ovulation has occurred until her menstrual cycle returns. Although breastfeeding is not considered an effective form of contraception, breast-feeding usually delays the return of both ovulation and menstruation. The length of the delay varies with the duration of lactation and the frequency of breast-feeding. While abstinence is one form of birth control and safe while breast-feeding, it may not be acceptable to this couple who is asking about a method that will allow them to resume sexual relations.

59. A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following? 1. Fat. 2. Iron. 3. Sodium. 4. Calcium.

1.Fat Breast milk has a higher fat content than cow's milk. Thirty to fifty-five percent of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk.

58. After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching? 1. "I need to increase my intake of vitamin D." 2. "I should drink at least five glasses of fluid daily." 3. "I need to get an extra 500 cal/day." 4. "I need to make sure I have enough calcium in my diet."

2. "I should drink at least five glasses of fluid daily." For the breast-feeding client, drinking at least 8 to 10 glasses of fluid a day is recommended. Breast-feeding women need an increased intake of vitamin D for calcium absorption. A breast-feeding woman requires an extra 500 cal/day above the recommended nonpregnancy intake to produce quality breast milk. Breast-feeding women need adequate calcium for blood clotting and strong bones and teeth.

49. The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? 1. G 4, P 1 client who is breast-feeding her infant. 2. G 3, P 3 client who is breast-feeding her infant. 3. G 2, P 2 cesarean client who is bottle-feeding her infant. 4. G 3, P 3 client who is bottle-feeding her infant.

2. G 3, P 3 client who is breast-feeding her infant. The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There are no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breastfeeding— places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has given birth to several children, but her choice to bottle-feed reduces her risk of pain.

47. A postpartum primiparous client is having difficulty breast-feeding her infant. The infant latches on to the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breast-feeding when she states: 1. "The baby needs to have as much of the nipple and areola in his mouth as possible to prevent sore and cracked nipples." 2. "I can put breast milk on my nipples to heal the sore areas." 3. "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." 4. "Feeding the baby for a half-hour on each side will not make my breasts sore."

3. "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." As much of the mother's nipple and areola need to be in the infant's mouth in order to establish a latch that does not cause nipple cracks or fissures. Having the nipple and the areola deep in the infant's mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking, and fissures. Breast milk has been found to heal nipples when placed on the nipple at the completion of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant's mouth.

63. After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching? 1. "I can let the milk sit out in a bottle for up to 10 hours." 2. "I'll be sure to label the milk with the date, time, and amount." 3. "I can safely store the milk for 3 days in the refrigerator." 4. "I can keep the milk in a deep freeze in clean glass bottles for up to 1 year."

3. "I can safely store the milk for 3 days in the refrigerator." Stored breast milk can be safely kept in the refrigerator for up to 7 days or in a deep freeze at 0°F (−18°C) for 12 months. Breast milk should be stored in glass containers because immunoglobulin tends to stick to plastic bottles. Breast milk can remain without refrigeration or loss of nutrients for up to 10 hours. The containers should be labeled with date, time, and amount to prevent inadvertent administration of spoiled milk. Frozen breast milk should be thawed in the refrigerator for a few hours, placed under warm tap water, and then shaken.

65. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following? 1. Apply an ice cube to the nipples. 2. Rub her nipples gently with lanolin cream. 3. Express a small amount of breast milk. 4. Offer the neonate a small amount of formula.

3. Express a small amount of breast milk. Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk flow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorgement. However, it may temporarily relieve the discomfort associated with breast engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary. Use of lanolin may cause sensitivity and irritation. Having frequent breast-feeding sessions, rather than offering the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion.

51. A diabetic postpartum client plans to breast-feed. The nurse determines that the client's understanding of breast-feeding instructions is sufficient when she states: 1. "Insulin will be transferred to the baby through breast milk." 2. "Breast-feeding is not recommended for diabetic mothers." 3. "Breast milk from diabetic mothers contains few antibodies." 4. "Breast-feeding will assist in lowering maternal blood glucose."

4. "Breast-feeding will assist in lowering maternal blood glucose." Breast-feeding consumes maternal calories and requires energy that increases the maternal basal metabolic rate and assists in lowering the maternal blood glucose level. Insulin is not transferred to the infant through breast milk. Breast-feeding is recommended for diabetic mothers because it does lower blood glucose levels. The number of antibodies in breast milk is not altered by maternal diabetes.

62. Which of the following client statements indicates effective teaching about burping a breast-fed neonate? 1. "Breast-fed babies who are burped frequently will take more on each breast." 2. "If I supplement the baby with formula, I will rarely have to burp him." 3. "I'll breast-feed my baby every 3 hours so I won't have to burp him." 4. "When I switch to the other breast, I'll burp the baby."

4. "When I switch to the other breast, I'll burp the baby." Breast-fed neonates do not swallow as much air as bottle-fed neonates, but they still need to be burped. Good times to burp the neonate are when the mother switches from one breast to the other and at the end of the breast-feeding session. Neonates do not eat more if they are burped frequently. Breast-feeding mothers are advised not to supplement the feedings with formula because this may cause nipple confusion and decrease milk production. If supplements are given, the baby still needs to be burped. Neonates who are fed every 3 hours still need to be burped.

46. The nurse is reviewing discharge instructions with a postpartum breast-feeding client who is going home. She has chosen medroxyprogesterone (Depo-Provera) as birth control. Which statement by the client identifies that she needs further instruction concerning birth control? 1. "I will wait for my 6-week checkup to get my first Depo-Provera shot." 2. "Depo-Provera injections last for 90 days." 3. "My milk supply should be well established before using Depo-Provera." 4. "You will give me my first Depo-Provera shot before I leave today."

4. "You will give me my first Depo-Provera shot before I leave today." Depo-Provera is a progestin contraceptive that can reduce the initial production of breast milk. It is given to a breast-feeding woman when she returns for the 6-week postpartum checkup. By this time, the milk supply is well established and will remain at that level. Depo-Provera is effective as a contraceptive for 90 days. Clients who are bottle-feeding may be given Depo-Provera prior to discharge from the hospital.

60. While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple? 1. Pull down gently on the neonate's chin and insert the nipple. 2. Squeeze both of the neonate's cheeks simultaneously. 3. Place the nipple into the neonate's mouth on top of the tongue. 4. Brush the neonate's lips lightly with the nipple.

4. Brush the neonate's lips lightly with the nipple. Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking. The neonate should be taught to open the mouth and grasp the nipple on his or her own. The neonate should not be forced to nurse.

64. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following? 1. Adrenalin. 2. Estrogen. 3. Prolactin. 4. Oxytocin.

4. Oxytocin Oxytocin stimulates the let-down reflex when milk is carried to the nipples. A lactating mother can experience the let-down reflex suddenly when she hears her baby cry or when she anticipates a feeding. Some mothers have reported feeling the let-down reflex just by thinking about the baby. Adrenalin may increase if the mother is excited, but this hormone has no direct influence on breastfeeding. Estrogen influences development of female secondary sex characteristics and controls menstruation. Prolactin stimulates milk production.

54. A primiparous client who is beginning to breast-feed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with: 1. More fat than breast milk. 2. Vitamin K, which the neonate lacks. 3. Delayed meconium passage. 4. Passive immunity from maternal antibodies.

4. Passive immunity from maternal antibodies. Colostrum is a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies (eg, immunoglobulin A). It is important for the neonate to receive colostrum for passive immunity. Colostrum is lower in fat and lactose than mature breast milk. Colostrum does not contain vitamin K. The neonate will produce vitamin K once a feeding pattern is established. Colostrum may speed, rather than delay, the passage of meconium.

57. A multiparous client, 28 hours after cesarean birth, who is breast-feeding has severe cramps or afterpains. The nurse explains that these are caused by which of the following? 1. Flatulence accumulation after a cesarean birth. 2. Healing of the abdominal incision after cesarean birth. 3. Adverse effects of the medications administered after birth. 4. Release of oxytocin during the breast-feeding session.

4. Release of oxytocin during the breast-feeding session. Breast-feeding stimulates oxytocin secretion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains. Flatulence may occur after a cesarean birth. However, the mother typically would have abdominal distention and a bloating feeling, not a "cramplike" feeling. Stretching of the tissues or healing may cause slight tenderness or itching, not cramping feelings of discomfort. Medications such as mild analgesics or stool softeners, commonly administered postpartum, typically do not cause cramping.