A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.Which of the following instructions should the nurse include?
Suggest the client apply warm compresses to the affected breast.
Recommend the client avoid wearing a nursing bra until symptoms resolve.
Encourage the client to limit oral fluid intake to decrease milk production.
Tell the client to apply hydrocortisone ointment to the affected area of the breast
The Correct Answer is A
Choice A rationale
Warm compresses can help alleviate pain and inflammation associated with mastitis. The heat from the compresses increases blood flow to the affected area, promoting healing and reducing discomfort.
Choice B rationale
Wearing a nursing bra can provide support and reduce discomfort for individuals with mastitis. Avoiding a nursing bra may lead to increased pain and discomfort due to lack of support.
Choice C rationale
Limiting oral fluid intake is not recommended for individuals with mastitis. Adequate hydration is essential for overall health and can help maintain milk production, which is important for breastfeeding mothers.
Choice D rationale
Hydrocortisone ointment is not typically recommended for treating mastitis. The primary treatment for mastitis includes antibiotics, pain relief, and supportive measures such as warm compresses and continued breastfeeding.
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Correct Answer is A
Explanation
Choice A rationale
Eating dry, bland foods in the morning can help alleviate nausea by providing a gentle start to the digestive system. Bland foods like crackers or toast are less likely to irritate the stomach lining and can help absorb stomach acids, reducing the feeling of nausea.
Choice B rationale
Taking an over-the-counter antacid is not recommended for nausea during pregnancy unless prescribed by a healthcare provider. Antacids are typically used to neutralize stomach acid and relieve heartburn, not nausea.
Choice C rationale
Restricting fluids to 1,000 mL/day is not advisable as it can lead to dehydration. Adequate hydration is essential during pregnancy to support the increased blood volume and amniotic fluid.
Choice D rationale
Increasing the intake of fresh fruits is beneficial for overall health but may not specifically address nausea. Some fruits can be acidic and might worsen nausea in some individuals.
Correct Answer is A
Explanation
Choice A rationale
A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.
Choice B rationale
Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.
Choice C rationale
No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.
Choice D rationale
The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.