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 B
Explanation
Choice A rationale
A large banana is not a significant source of dietary calcium. While bananas are nutritious and provide potassium and vitamin C, they do not contain enough calcium to meet the needs of a pregnant client who does not consume dairy products.
Choice B rationale
Kale is an excellent non-dairy source of calcium. Dark leafy greens like kale are rich in calcium, with approximately 90 mg of calcium per cup when cooked. Including kale in the diet can help pregnant women meet their calcium needs, especially if they do not consume dairy products.
Choice C rationale
A baked potato is not a significant source of dietary calcium. While potatoes provide several nutrients, including potassium and vitamin C, they do not contain enough calcium to be recommended as a primary source for a pregnant client who does not consume dairy products.
Choice D rationale
White corn is not a significant source of dietary calcium. While it can contribute to overall nutritional intake, it does not provide enough calcium to meet the needs of a pregnant client who does not consume dairy products.
Correct Answer is B
Explanation
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.