A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast. Which of the following Instructions should the nurse include?
Tell the client to apply hydrocortisone ointment to the affected area of the breast.
Recommend the client avoid wearing a nursing bra until symptoms resolve.
Suggest the client apply warm compresses to the affected breast.
Encourage the client to limit oral fluid intake to decrease milk production.
The Correct Answer is C
A) Incorrect- Hydrocortisone ointment is not typically recommended for treating mastitis, as it might not address the underlying infection.
B) Incorrect- Wearing a well-fitting, supportive nursing bra can actually help alleviate discomfort and is not typically contraindicated in cases of mastitis.
C) Correct - Applying warm compresses to the affected breast can help reduce pain and discomfort associated with mastitis. Warmth can improve blood flow and promote milk flow.
D) Incorrect- Encouraging the client to limit oral fluid intake to decrease milk production is not a recommended approach, as maintaining proper hydration is important, especially when dealing with infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A) Incorrect - Applying oxygen is not the priority action in the case of excessive vaginal bleeding and a boggy uterus. Oxygen therapy would be appropriate if there were signs of respiratory distress or decreased oxygen saturation, but it does not directly address the primary concern of uterine atony and bleeding.
B) Incorrect - Administering methylergonovine might be appropriate, but the priority is to address the uterine atony with fundal massage first. Fundal massage helps stimulate uterine contractions and control bleeding, which is crucial in this scenario.
C) Incorrect - Encouraging the client to empty her bladder is important, but it is not the first action to take in the case of excessive bleeding and uterine atony. Immediate intervention to control the bleeding takes precedence.
D) Correct - Initiating fundal massage is the priority action in this situation. A boggy uterus with excessive vaginal bleeding indicates uterine atony, which is a potentially life-threatening condition requiring immediate intervention to prevent further bleeding.
Fundal massage helps the uterus contract and control bleeding. Addressing uterine atony is critical to prevent further hemorrhage and stabilize the client's condition.
Correct Answer is C
Explanation
A) Incorrect- Applying ointment to the skin during phototherapy is typically avoided as it can interfere with the effectiveness of the therapy.
B) Incorrect- Giving distilled water after feedings is not a typical intervention for phototherapy.
C) Correct - Repositioning the newborn every 2 to 3 hours is important to ensure adequate exposure of the skin to the phototherapy lights and to prevent pressure points.
D) Incorrect- Monitoring blood glucose levels is not a standard intervention during phototherapy unless there are specific indications for doing so.
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