Question

The nurse is evaluating the effectiveness of an intervention when assisting a woman

whose baby has been latched to the nipple only rather than to the nipple and the
areola. Which response would indicate that further intervention is needed?
1. The client states that the pain has decreased.
2. The nurse hears the baby swallow after each suck.
3. The baby's jaws move up and down once every second.
4. The baby's cheeks move in and out with each suck.

Answer 1

Option 3, when the baby's jaws move up and down once every second, would indicate the need for further intervention in this case.

Step-by-step explanation:

The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. In this case, the response that would indicate that further intervention is needed is option 3, when the baby's jaws move up and down once every second.

When a baby is latched properly and effectively, their jaws will move in a rhythmic, wave-like motion, with a suck followed by a swallow. This indicates that the baby is transferring milk efficiently from the breast. In contrast, if the baby's jaws are moving up and down at a faster rate, it may indicate an ineffective latch and a need for further intervention.

Therefore, option 3 is the response that would indicate the need for further intervention.