A nurse is reinforcing discharge instructions about breastfeeding with a client.Which of the following statements should the nurse make?
You should feed your baby six times a day.
You should recognize that your baby sucking on his hands is a hunger cue.
You should feed your baby for 10 minutes on each breast.
You should wake your baby at least every 6 hours at night for feedings.
The Correct Answer is B
Choice A rationale
Feeding the baby six times a day is not sufficient. Newborns typically need to be fed 8-12 times in 24 hours to ensure they receive adequate nutrition and to establish a good milk supply.
Choice B rationale
Recognizing that the baby sucking on his hands is a hunger cue is correct. This is an early sign of hunger, and responding to these cues helps ensure the baby is fed before becoming too upset.
Choice C rationale
Feeding the baby for 10 minutes on each breast may not be adequate. The duration of feeding can vary, and it is important to allow the baby to feed until they are satisfied, which may take longer than 10 minutes.
Choice D rationale
Waking the baby at least every 6 hours at night for feedings is not recommended. Newborns should be fed more frequently, typically every 2-3 hours, including during the night, to ensure they receive enough nutrition.
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Correct Answer is A
Explanation
Choice A rationale
Warm compresses can help alleviate pain and inflammation associated with mastitis. The heat from the compresses increases blood flow to the affected area, promoting healing and reducing discomfort.
Choice B rationale
Wearing a nursing bra can provide support and reduce discomfort for individuals with mastitis. Avoiding a nursing bra may lead to increased pain and discomfort due to lack of support.
Choice C rationale
Limiting oral fluid intake is not recommended for individuals with mastitis. Adequate hydration is essential for overall health and can help maintain milk production, which is important for breastfeeding mothers.
Choice D rationale
Hydrocortisone ointment is not typically recommended for treating mastitis. The primary treatment for mastitis includes antibiotics, pain relief, and supportive measures such as warm compresses and continued breastfeeding.
Correct Answer is ["F","G","H"]
Explanation
Choice A rationale:
Deep tendon reflexes of 1+ are considered normal and do not indicate any immediate concern. Reflexes are graded on a scale from 0 to 4+, with 2+ being normal. A 1+ reflex is slightly diminished but can be normal in some individuals.
Choice B rationale:
A pain rating of 3 on a scale of 0 to 10 is relatively low and manageable. Postpartum pain is expected, and a rating of 3 does not indicate severe pain that requires immediate intervention.
Choice C rationale:
The blood pressure reading of 136/86 mm Hg is slightly elevated but not alarming. Postpartum blood pressure can fluctuate, and this reading does not indicate a hypertensive crisis.
Choice D rationale:
Peripheral edema of 2+ in the bilateral lower extremities is common postpartum due to fluid retention and is not typically a cause for immediate concern unless accompanied by other symptoms such as severe pain or redness.
Choice E rationale:
Soft breasts with intact nipples are normal findings in the early postpartum period, especially if the client is breastfeeding. There is no indication of issues such as mastitis or engorgement.
Choice F rationale:
A large amount of lochia rubra is concerning as it may indicate postpartum hemorrhage. Lochia should gradually decrease in amount and change in color over time. A large amount of bright red blood suggests excessive bleeding that requires immediate follow-up.
Choice G rationale:
A soft uterine tone is abnormal and can indicate uterine atony, which is a leading cause of postpartum hemorrhage. The uterus should be firm and contracted to prevent excessive bleeding.
Choice H rationale:
Lateral deviation of the uterus can indicate a full bladder, which can prevent the uterus from contracting properly and lead to increased bleeding. This requires immediate attention to ensure the bladder is emptied and the uterus can contract effectively.