A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?
"I should crush cabbage leaves and place them on my breast.".
"I will wear a snug-fitting bra.".
"I should stimulate my nipples by squeezing softly.".
"I will apply ice packs to my breasts.".
The Correct Answer is C
Choice A rationale:
Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.
Choice B rationale:
Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.
Choice C rationale:
Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.
Choice D rationale:
Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.
Choice B rationale:
Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.
Choice C rationale:
Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.
Choice D rationale:
Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.
Choice E rationale:
Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.
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