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 A
Explanation
Choice A rationale:
Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.
Choice B rationale:
Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.
Choice C rationale:
Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.
Choice D rationale:
Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.
Correct Answer is ["B","C","E","F"]
Explanation
The four findings that require follow-up are B, C, E, and F.
Rationale:
- Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
- Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
- Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
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