A nurse is caring for a client who is postpartum and has inverted nipples. Which of the following actions should the nurse take?
Encourage the client to wear an underwire bra.
Place breast shells in the client's bra.
Provide plastic-lined breast pads.
Have the client apply breast cream on a regular basis.
The Correct Answer is B
Choice A rationale
Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.
Choice B rationale
Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.
Choice C rationale
Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.
Choice D rationale
Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.
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Correct Answer is C
Explanation
Choice A rationale
Taking an over-the-counter antacid is not recommended for managing nausea during pregnancy without consulting a healthcare provider. Some antacids contain ingredients that may not be safe during pregnancy.
Choice B rationale
Increasing intake of fresh fruits might help with hydration and nutrition but is not specifically effective in managing morning nausea. Some fruits might even exacerbate nausea due to their acidity.
Choice C rationale
Eating dry, bland foods in the morning can help manage nausea for pregnant clients. Foods like crackers, toast, and cereals are easy on the stomach and can help reduce morning sickness.
Choice D rationale
Restricting fluids to 1,000 mL/day is not advisable. Proper hydration is crucial during pregnancy, and such restriction can lead to dehydration and other complications. Fluids should be encouraged rather than restricted.
Correct Answer is D
Explanation
Choice A rationale
Nausea can be a side effect of magnesium sulfate, but it is not a specific indication of toxicity. Other symptoms are more directly indicative of magnesium sulfate overdose.
Choice B rationale
Facial flushing is a common side effect of magnesium sulfate but is not a sign of toxicity. It typically occurs at therapeutic levels and is not a reliable indicator of overdose.
Choice C rationale
Urine output of 40 mL/hr is within normal limits for an adult and does not indicate magnesium sulfate toxicity. However, significantly decreased urine output could be concerning.
Choice D rationale
Respiratory rate of 10/min is a critical sign of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a rate of 10 breaths per minute or less indicates that the patient may be experiencing toxic effects, necessitating immediate medical intervention.