A nurse is reinforcing teaching with a client who is breastfeeding and reports nipple soreness. Which of the following recommendations should the nurse include in the teaching?
"Increase the frequency of feedings from the affected nipple."
"Apply vitamin E oil to the affected nipple before each feeding."
"Wash the affected nipple with soap and water before each feeding."
"Expose the affected nipple to the air between feedings."
The Correct Answer is D
A. Increasing the frequency of feedings from the affected nipple can worsen soreness. It’s important to address the underlying cause of soreness, which may involve evaluating latch technique or positioning rather than increasing feeding frequency.
B. Vitamin E oil is not recommended for sore nipples as it can cause irritation. Proper care involves managing latch and positioning, and sometimes using a lanolin cream rather than oils or other substances.
C. Washing the nipple with soap and water before each feeding can remove natural oils and lead to further irritation. The nipple should be gently cleaned with water, if necessary, and kept clean without over-washing.
D. Exposing the affected nipple to the air between feedings helps with healing and reduces moisture, which can exacerbate soreness. Allowing the nipple to air-dry can promote healing and reduce discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Magnesium sulfate is used to manage preeclampsia or prevent preterm labor, not for treating an ectopic pregnancy. It does not address the issue of an unruptured ectopic pregnancy.
B. Methotrexate is a medication used to treat an unruptured ectopic pregnancy by dissolving the ectopic tissue and allowing it to be reabsorbed by the body. It is a first-line treatment for early, unruptured ectopic pregnancies to prevent complications.
C. Calcium gluconate is used to treat hypocalcemia or to counteract the effects of magnesium sulfate in preeclampsia, not for ectopic pregnancies. It is not relevant to the management of an unruptured ectopic pregnancy.
D. Terbutaline is used to manage preterm labor by relaxing uterine contractions. It does not address the treatment of an ectopic pregnancy and is not indicated for this condition.
Correct Answer is C
Explanation
A. Blood pressure 156/80 mm Hg is incorrect. While this blood pressure reading is elevated, hypertension is not a typical immediate sign of postpartum hemorrhage. Hemorrhage is more commonly associated with hypotension (low blood pressure) due to fluid loss.
B. Temperature 38.3° C (101° F) is incorrect. A mild fever may be common in the first 24 hours postpartum due to normal inflammatory responses. It is not specifically indicative of postpartum hemorrhage, though a persistent fever could indicate an infection.
C. Respiratory rate 32/min is correct. An increased respiratory rate can be a sign of hypovolemia (due to significant blood loss), which may occur with postpartum hemorrhage. The body compensates for decreased blood volume by increasing the respiratory rate.
D. Apical pulse 66/min is incorrect. A heart rate of 66/min is within normal limits and would not be indicative of postpartum hemorrhage. In fact, a tachycardic (elevated) heart rate is more concerning in the case of hemorrhage as the body tries to compensate for blood loss.
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