A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?
"I won't wear a bra during the daytime.".
"I'll apply cold compresses 20 min before each feeding.".
"I'll feed my baby every 2 hours.".
"I will stop breastfeeding until I am done with the antibiotics.".
The Correct Answer is C
Choice A rationale:
Wearing a supportive bra can actually help to manage engorgement, so it's not recommended to avoid wearing one during the day.
Choice B rationale:
Cold compresses are typically applied after feeding to reduce swelling, not before. Applying them before might hinder the milk let-down reflex.
Choice C rationale:
Frequent feeding can help to alleviate engorgement by ensuring that the breasts are being emptied regularly.
Choice D rationale:
Stopping breastfeeding until finishing antibiotics is not advisable, as it can lead to decreased milk supply and potential issues with engorgement. Antibiotics prescribed by a healthcare provider are usually safe to take while breastfeeding, and interrupting breastfeeding can exacerbate the engorgement problem. This choice is not appropriate for managing breast engorgement and is therefore incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 130/min in a newborn is within the normal range. The normal heart rate for a newborn is generally between 110 to 160 beats per minute (bpm). As the newborn's heart rate falls within this range, the nurse should document it as an expected finding and continue routine monitoring.
Choice B rationale:
Calling the neonatologist to assess the newborn for an apical pulse of 130/min is not warranted as it is a normal finding. The nurse should only notify the neonatologist if there are abnormal vital signs or concerning clinical signs.
Choice C rationale:
Asking another nurse to verify the heart rate is unnecessary in this scenario. The nurse can independently measure the apical pulse and document the finding as long as it falls within the normal range for newborns.
Choice D rationale:
Preparing the newborn for transport to the Neonatal Intensive Care Unit (NICU) is not indicated for a normal apical pulse rate. Transporting a newborn to the NICU is typically reserved for critical or unstable conditions. In this case, the normal heart rate of 130/min does not warrant NICU transport.
Correct Answer is B
Explanation
"Baby powder will help prevent a diaper rash.”.
Choice A rationale:
"I will use mild soap”. indicates an appropriate understanding of newborn bathing. Mild soap is suitable for newborn skin to avoid irritation.
Choice B rationale:
This is the correct answer. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled and may lead to skin irritation. Therefore, the client needs further teaching about the use of baby powder.
Choice C rationale:
"I will test the water on my wrist for temperature before bathing”. demonstrates proper safety measures, ensuring the water is not too hot for the baby.
Choice D rationale:
"I will use a basin during bathing”. is a reasonable approach to bathing the newborn and does not indicate a need for further teaching.
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