A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is not planning on breastfeeding. Which of the following statements by the client indicates she understood the teaching?
“I should pump out the milk when my breasts become engorged.”.
“I will not wear a bra throughout the day.”.
“I should apply hot packs to my breasts.”.
“I will avoid stimulation to my nipples.”.
The Correct Answer is D
Choice A rationale
Pumping out the milk when breasts become engorged can provide temporary relief, but it can also stimulate further milk production, leading to continued engorgement. This is not recommended for clients who are not planning to breastfeed.
Choice B rationale
Not wearing a bra throughout the day can lead to discomfort and inadequate support for engorged breasts. Wearing a supportive bra, such as a sports bra, can help alleviate discomfort and provide necessary support.
Choice C rationale
Applying hot packs to the breasts can increase blood flow and exacerbate engorgement. Cold packs or ice packs are recommended to reduce swelling and provide relief from discomfort.
Choice D rationale
Avoiding stimulation to the nipples is an effective measure to reduce milk production and alleviate breast engorgement. This includes avoiding activities that may stimulate the nipples, such as pumping or hand expressing milk.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A rationale
Asking the client to rate her pain is important for assessing discomfort, but it does not address the immediate issue of a deviated fundus. A deviated fundus often indicates a full bladder, which can impede uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
Encouraging the client to perform Kegel exercises is beneficial for pelvic floor strengthening but does not address the immediate concern of a deviated fundus. The priority is to ensure the uterus can contract properly.
Choice C rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus, preventing it from contracting effectively and increasing the risk of hemorrhage. Voiding helps the uterus return to its proper position and function.
Choice D rationale
Encouraging the client to move to the left lateral position may provide comfort but does not address the underlying issue of a full bladder causing uterine displacement.
Correct Answer is D
Explanation
Choice A rationale
Swelling in both breasts is more indicative of engorgement rather than mastitis. Mastitis typically affects only one breast.
Choice B rationale
A white patch on a nipple is more likely a sign of a yeast infection (thrush) rather than mastitis.
Choice C rationale
Cracked and bleeding nipples can be a risk factor for mastitis but are not a definitive sign of the condition.
Choice D rationale
A red and painful area in one breast is a classic sign of mastitis. This condition is often accompanied by flu-like symptoms such as fever and malaise.