Difficulty: Medium
Average Score: 63%
Simulated
The nurse is evaluating a breastfeeding session. The nurse determines that the infant has appropriately latched on to the motherÔÇÖs breast when which observations are made? Select all that apply.
Correct answer
A,D,E,F
Rationale
If the latch is correct, the mother should feel only a firm tugging and not pain or pinching when the infant sucks. A smacking or clicking noise heard when the infant sucks is an indication that the latch is incorrect and that the infantÔÇÖs tongue may be inappropriately placed. Sucking only on the motherÔÇÖs nipple will cause sore nipples, and milk will not be ejected from the milk ducts. When an infant is correctly latched to the breast, 2 to 3 centimeters (1/3 to 3/4 inch) of areola should be covered by the infantÔÇÖs mouth. If this occurs, it will result in the infantÔÇÖs nose, mouth, and chin touching the breast. When the infant is latched correctly, the cheeks will be rounded rather than dimpled. When the infant is latched correctly, the swallowing will be audible.