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 D
Explanation
A. This is not a primary consideration before bathing a newborn. The timing of the last feeding is more relevant to assessing the risk of hypoglycemia rather than determining readiness for a bath.
B. This temperature is slightly below the recommended range for newborns (36.5°C to 37.5°C). Bathing should be delayed until the newborn's temperature is stable.
C. While care of the umbilical cord is important, it does not determine the timing of the first bath. The cord can be kept dry even if the baby is bathed.
D. Ensuring that the newborn has maintained a stable body temperature for at least 2 hours is crucial before giving the first bath. Bathing can cause a drop in body temperature, so it's essential that the newborn's thermoregulation is stable to avoid hypothermia.
Correct Answer is C
Explanation
Choice A rationale:
The liver's job related to bilirubin is not changing conjugated bilirubin to unconjugated. Conjugated bilirubin is the water-soluble form of bilirubin that is excreted in bile and urine. Unconjugated bilirubin, on the other hand, is the fat-soluble form, which is transported to the liver and conjugated to become water-soluble. The conversion goes from unconjugated to conjugated, not the other way around.
Choice B rationale:
The liver's job related to bilirubin is not the synthesis of vitamin K. The liver is responsible for synthesizing clotting factors, including factors II (prothrombin), VII, IX, and X, but not vitamin K itself. Vitamin K is obtained from dietary sources or supplements and is essential for blood clotting.
Choice C rationale:
This choice is the correct answer. The liver's primary function related to bilirubin is changing unconjugated bilirubin to conjugated bilirubin. As mentioned earlier, unconjugated bilirubin is produced from the breakdown of heme in old red blood cells, and it needs to be processed in the liver to become water-soluble and eventually excreted in bile and urine.
Choice D rationale:
The liver's job related to bilirubin does not involve the removal of meconium. Meconium is the first stool passed by a newborn, and its elimination is unrelated to the liver's function in processing bilirubin.
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