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 A
Explanation
Choice A rationale
Assisting the client's partner to apply counterpressure to the sacrum can help alleviate the low-back pain associated with early labor by providing direct pressure to the area experiencing discomfort.
Choice B rationale
Maintaining the client on bed rest until active labor begins is not typically recommended, as mobility can help with the progression of labor and pain management.
Choice C rationale
Inserting an indwelling urinary catheter is not necessary for managing low-back pain in early labor and can increase the risk of infection and discomfort.
Choice D rationale
Teaching the client to hold their breath during contractions is not advisable, as it can lead to increased pain and decreased oxygenation for both the mother and baby. Breathing techniques are usually recommended to manage pain and ensure adequate oxygen delivery. .
Correct Answer is D
Explanation
Choice A rationale
Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.
Choice B rationale
Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.
Choice C rationale
Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.
Choice D rationale
Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.