A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn.
Which of the following instructions should the nurse include in the teaching?
"You should limit your fluid intake to 1 liter per day.”
"You should manually express milk when engorgement occurs.”
"You should wear a snug-fitting bra continuously for 72 hours.”
"You should apply moist heat to your breasts four times per day.”
The Correct Answer is C
Choice A rationale:
Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.
Choice B rationale:
Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs
Choice C rationale:
Wearing a snug-fitting bra can provide support and comfort.
Choice D rationale:
Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.
Choice B rationale:
Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.
Choice C rationale:
Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.
Choice D rationale:
Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.
Correct Answer is C
Explanation
- A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
- B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
- C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
- D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
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