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 B
Explanation
Choice A rationale
A client whose labor lasted for 6 hours is not necessarily a priority unless other complications are present. Duration of labor alone does not indicate an urgent need for immediate attention postpartum.
Choice B rationale
A client who received magnesium sulfate during labor should be seen first due to the potential for serious side effects such as respiratory depression, hypotonia in the newborn, and maternal complications. Magnesium sulfate is used to prevent seizures in clients with preeclampsia and requires close monitoring.
Choice C rationale
A client with a history of oligohydramnios needs monitoring, but this condition alone does not take precedence over the immediate postpartum risks associated with magnesium sulfate.
Choice D rationale
A client whose newborn is having difficulty latching-on needs support and assistance with breastfeeding. While important, this issue is not as urgent as monitoring the effects of magnesium sulfate in the client described in Choice B.
Correct Answer is A
Explanation
Choice A rationale
Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.
Choice C rationale
Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.
Choice D rationale
A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.