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
The correct answer is choice C and explain why.Nipple stimulation can cause uterine contractions and increase the risk of preterm labor, especially in a twin gestation.
The client should avoid nipple stimulation until term or as instructed by the provider.
Choice A is wrong because cocoa butter can help moisturize the skin and prevent itching and dryness.
It does not prevent stretch marks, but it is not harmful.
Choice B is wrong because resting several times a day, lying on the left side, can improve blood flow to the uterus and reduce swelling in the lower extremities.
It is a recommended self-care measure for the third trimester of pregnancy.
Choice D is wrong because drinking at least eight glasses of water a day can prevent dehydration, constipation, and urinary tract infections.
It can also help regulate body temperature and amniotic fluid volume.
Normal ranges for twin gestation are similar to singleton gestation, except for fundal height and weight gain.
The fundal height should be measured in centimeters from the pubic symphysis to the top of the uterus.
It should be approximately equal to the number of weeks of gestation plus or minus 4 cm until 32 weeks, then it may plateau or decrease slightly.
The weight gain should be between 35 and 45 pounds for a normal-weight woman, 25 to 42 pounds for an overweight woman, and 15 to 25 pounds for an obese woman.
Correct Answer is B
Explanation
The correct answer is choice B. The administration route of terbutaline will be changed from intravenous to oral.
This is because terbutaline is a medication that can be used to suppress preterm labor by relaxing the uterine smooth muscle.It can be given subcutaneously or intravenously for acute episodes of preterm labor, but it is not recommended for long-term use due to the risk of serious maternal and fetal adverse effects.Therefore, if the client’s condition stabilizes, the administration route of terbutaline will be changed from intravenous to oral, which has a lower bioavailability and less systemic effects.
Choice A is wrong because terbutaline is not usually self-administered parenterally by the client at home.It requires a trained health professional to give it as a shot under the skin or through a vein.
Choice C is wrong because the client does not need to remain in a private room without visitors until she has been without contractions for 48 hours.
This is an unnecessary restriction that may increase the client’s stress and anxiety.
The client should be encouraged to have social support and emotional comfort during this time.
Choice D is wrong because the client should not ambulate in the hallway after 12 hours without contractions.
This may stimulate uterine activity and cause a recurrence of preterm labor.
The client should follow the provider’s instructions on bed rest and activity limitations.
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