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 D
Explanation
Choice A rationale
Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.
Choice B rationale
Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.
Choice C rationale
A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.
Choice D rationale
Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.
Correct Answer is D
Explanation
Choice A rationale
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.