A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

Instruct the client to wash their hands prior to breastfeeding.

Teach the client about proper latching-on techniques.

Encourage the client to alternate breastfeeding with formula feeding.

Instruct the client to avoid using a breast pump.

Encourage the client to allow their nipples to air dry after feedings.

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:

Instructing the client to wash their hands before breastfeeding helps prevent the transmission of infection to the breast and the baby.

Choice B rationale:

Teaching the client about proper latching-on techniques ensures effective breastfeeding, reduces the risk of nipple damage, and promotes comfort for both the client and the baby.

Choice C rationale:

Encouraging the client to alternate breastfeeding with formula feeding is not recommended for a client with mastitis. Mastitis is an inflammation of the breast tissue often caused by bacterial infection, and continuing breastfeeding helps to clear the infection and maintain milk supply.

Choice D rationale:

Instructing the client to avoid using a breast pump is not necessary in this situation. Breastfeeding and pumping can continue to help drain the breast adequately, which is essential for resolving mastitis.

Choice E rationale:

Encouraging the client to allow their nipples to air dry after feedings helps promote healing and prevents further irritation to the nipples.

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Correct Answer is A

Explanation

Choice A rationale:

Terbutaline is a medication commonly used to stop preterm labor by relaxing the uterine muscles. However, it is contraindicated in clients with heart disease or certain cardiac conditions, as it can cause cardiovascular side effects such as increased heart rate, palpitations, and potential arrhythmias.

Choice B rationale:

Cervical dilation of 2 cm is a typical sign of preterm labor, and the prescription for terbutaline is appropriate to prevent further cervical dilation and delay delivery.

Choice C rationale:

A gestational age of 34 weeks indicates preterm labor, which is precisely the scenario where terbutaline would be administered to halt labor progression and extend the pregnancy.

Choice D rationale:

Allergy to penicillin is unrelated to the administration of terbutaline, as they are different medications with distinct mechanisms of action and side effects.

A. Check the newborn's temperature every 8 hr. B. Apply moisturizing lotion to the newborn's skin every 4 hr. C. Give the newborn 1 oz of glucose water every 4 hr. D. Reposition the newborn every 2 to 3 hr.

Correct Answer is D

Explanation

Choice A rationale:

Checking the newborn's temperature every 8 hours is not directly related to managing hyperbilirubinemia or phototherapy. Monitoring the newborn's temperature is important, but it should be done more frequently, especially during phototherapy, as infants are at risk of developing hypothermia.

Choice B rationale:

Applying moisturizing lotion to the newborn's skin every 4 hours is not a necessary intervention for hyperbilirubinemia or phototherapy. While skin care is important for all newborns, it is not a specific intervention for this condition.

Choice C rationale:

Giving the newborn 1 oz of glucose water every 4 hours is not an appropriate intervention for hyperbilirubinemia. Glucose water is not a recommended treatment for this condition.

Instead, phototherapy helps break down the bilirubin and promote its elimination from the body.

Choice D rationale:

Repositioning the newborn every 2 to 3 hours is the correct intervention. Repositioning helps ensure even exposure of the baby's skin to the phototherapy lights, maximizing its effectiveness in reducing bilirubin levels. Additionally, repositioning prevents pressure ulcers and promotes comfort for the infant during treatment.

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A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?

Correct Answer is A

Explanation

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

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