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 ["The medical term for the soft spot on a baby's skull is fontanelle (or fontanel)."]
Explanation
The medical term for the soft spot on a baby's skull is fontanelle (or fontanel). Fontanelles are gaps between the bones of the skull that allow for the baby's brain to grow and accommodate rapid brain development during infancy. There are typically two fontanelles in a newborn's skull: the anterior fontanelle (located at the top/front of the head) and the posterior fontanelle (located at the back of the head). These fontanelles are composed of connective tissue and remain open during the early months of life, gradually closing as the baby's skull bones fuse together over time. Healthcare professionals often assess fontanelles during routine physical exams of infants. The fontanelle's size and tension can provide valuable information about the baby's hydration status, intracranial pressure, and neurological development.
Normally, the fontanelles should feel relatively soft and flat, indicating proper hydration and brain development. If the fontanelles are sunken or overly tense, it may suggest dehydration or increased intracranial pressure, which requires further evaluation and management. The proper examination of fontanelles is an essential part of newborn care, and any abnormalities observed during assessment should be promptly reported to the healthcare provider for appropriate evaluation and intervention.
Correct Answer is C
Explanation
Choice A rationale:
Placing the newborn in a radiant warmer may provide warmth, but it does not address the observed signs of respiratory distress, jitteriness, and lethargy. These signs indicate potential respiratory and neurological issues, which need to be assessed and managed promptly.
Choice B rationale:
Initiating phototherapy is not appropriate for the observed signs of respiratory distress, jitteriness, and lethargy. Phototherapy is used to treat neonatal jaundice caused by elevated bilirubin levels, which is not evident from the given information.
Choice C rationale:
The nurse should obtain blood glucose by heel stick to assess the newborn's blood sugar levels. The signs of jitteriness and lethargy may be indicative of hypoglycemia (low blood sugar), which is common in newborns. Early detection and intervention are crucial to prevent complications and ensure the baby's well-being.
Choice D rationale:
Measuring the newborn's blood pressure is not the priority at this moment. The observed signs suggest respiratory distress and potential hypoglycemia, which need immediate attention. Blood pressure assessment may be important later on, but it is not the first action the nurse should take based on the given information.
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