A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?
Wearing a loose-fitting bra to prevent nipple irritation.
Express small amounts of milk from the breasts to relieve the pressure.
Run warm water on her breasts during a shower.
Apply ice to the breasts for comfort.
The Correct Answer is D
A. Wearing a loose-fitting bra may provide comfort but does not address the underlying issue of engorgement.
B. Expressing small amounts of milk may stimulate further milk production and is not recommended in cases of bottle-feeding.
C. Running warm water on the breasts may increase blood flow and exacerbate swelling.
D. Cold compresses or ice are more appropriate for relieving discomfort and reducing swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drying the newborn's skin thoroughly helps reduce evaporative heat loss by removing wetness and promoting warmth.
B. Preventing air drafts is important to reduce convective heat loss.
C. Placing the newborn on a warm surface helps prevent conductive heat loss.
D. Maintaining ambient room temperature is important but does not directly address evaporative heat loss.
Correct Answer is B
Explanation
A. Moist lung sounds in this context are not indicative of an emergency situation requiring immediate notification of the pediatrician.
B. Moist lung sounds in a baby born by cesarean section are common and may be due to retained lung fluid, often resolving within the first 24 hours after birth. This is because the baby does not experience the same compression of the chest during delivery as a baby born vaginally, which helps to expel some of the fluid from the lungs.
C. Aspiration of surfactant is not a common or likely occurrence.
D. Moist lung sounds are not typically indicative of a pneumothorax, especially in the absence of other signs and symptoms.
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