A patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?
Manually express colostrum as necessary.
Apply hot compresses to the breasts.
Massage the breast tissue surrounding the areola.
Wear a supportive bra.
The Correct Answer is D
The correct answer is choice D. Wear a supportive bra. This will help suppress lactation and reduce the discomfort of engorgement.
The other choices are wrong because:
• Choice A. Manually express colostrum as necessary. This will stimulate milk production and prolong engorgement.
• Choice B. Apply hot compresses to the breasts. This will increase blood flow and swelling in the breasts and worsen engorgement.
• Choice C. Massage the breast tissue surrounding the areola. This will also stimulate milk production and prolong engorgement.
Normal ranges for breast engorgement are not applicable as it is a subjective experience that varies among women. However, some signs of engorgement include firm, tender, swollen breasts, flat or inverted nipples, and low-grade fever. Engorgement usually resolves within 24 to 36 hours after it begins.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.
Choice A: Obtain a full history is wrong because it is not the most urgent action.
A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.
Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.
Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.
Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.
Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.
Correct Answer is B
Explanation
Massaging the uterus helps it contract and prevent excessive bleeding after delivery.Uterine atony is a condition where the uterus does not contract enough to clamp the blood vessels that supply the placenta, leading to postpartum hemorrhage.Uterine massage is one of the interventions to treat uterine atony and restore uterine tone.
Choice A is wrong because having the client void frequently does not directly affect the uterine contraction.However, a full bladder can interfere with uterine contraction and cause displacement of the uterus, so it is important to monitor the bladder status and empty it as needed.
Choice C is wrong because having the client in a side-lying position for comfort does not help with uterine contraction.However, this position may be beneficial for other reasons, such as reducing edema and pain in the perineal area.
Choice D is wrong because keeping the patient on strict bed rest for 24 hours to avoid stress on the uterus does not help with uterine contraction.In fact, early ambulation after delivery can help prevent thromboembolic complications and promote recovery.
Normal ranges for postpartum blood loss are less than 500 mL for vaginal delivery and less than 1000 mL for cesarean delivery.Postpartum hemorrhage is defined as blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after birth.
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