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. Remind the patient that the nurse will stay with her during the examination.
This measure would help reduce the patient’s anxiety by providing emotional support and reassurance.
The patient may feel scared, embarrassed, or vulnerable during the pelvic examination, especially since she is young and pregnant.
Having a trusted person with her can help her cope with these feelings.
Choice A is wrong because it may imply that the examination will be painful and increase the patient’s anxiety.
Choice B is wrong because it may make the patient feel like she is not being treated as an individual and that her concerns are not valid.
Choice D is wrong because it may make the patient feel rushed or pressured and not allow her to ask questions or express her feelings.
Correct Answer is D
Explanation
This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.
The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.
Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.
However, this is not related to epidural anesthesia.
Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).
However, this is not related to epidural anesthesia.
Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.
Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.
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