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.
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Correct Answer is A
Explanation
Choice A rationale
Asking the client if she has thoughts of or considered harming herself or her newborn is the priority action. This assessment is crucial for identifying postpartum depression and potential risks to the client and her newborn. Early identification and intervention can prevent harm.
Choice B rationale
Anticipating a prescription for an antidepressant is important but secondary to assessing immediate safety concerns. Medication can be part of the treatment plan after assessing the client’s mental state.
Choice C rationale
Assisting the family to identify prior use of positive coping skills is beneficial for long-term management but is not the immediate priority. The nurse must first ensure the client’s and newborn’s safety.
Choice D rationale
Reinforcing postpartum and newborn care discharge teaching is important for overall care but does not address the immediate concern of potential harm due to postpartum depression.
Correct Answer is D
Explanation
Choice A rationale
The rubella vaccine should not be taken during pregnancy. It is a live attenuated vaccine, and there is a theoretical risk of harm to the developing fetus. Therefore, it is recommended to receive the vaccine before pregnancy.
Choice B rationale
The rubella vaccine is not recommended during each pregnancy. It is typically given as part of the MMR (measles, mumps, rubella) vaccine series in childhood, and immunity is usually lifelong. A booster dose is not needed during each pregnancy.
Choice C rationale
The rubella vaccine is not related to the Rh status of the baby. The vaccine is given to prevent rubella infection, which can cause serious birth defects if contracted during pregnancy.
Choice D rationale
The correct statement is that the client should avoid pregnancy for 28 days after receiving the rubella vaccine. This is to ensure that the live attenuated virus does not pose a risk to a developing fetus.