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A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis.Which of the following responses should the nurse make?

A.

Completely empty each breast at each feeding or use a pump.

B.

Nurse the infant only on the unaffected breast until resolved.

C.

Wear a tight-fitting bra until lactation has ceased.

D.

Limit the amount of time the infant nurses on each breast.

Answer and Explanation

The Correct Answer is A

Choice A rationale

 

Completely emptying each breast at each feeding or using a pump helps prevent milk stasis, which can lead to mastitis. Ensuring the breasts are fully emptied reduces the risk of blocked ducts and infection.

 

Choice B rationale

 

Nursing on only the unaffected breast can lead to engorgement and worsening of mastitis in the affected breast. It is important to continue breastfeeding on both sides to maintain milk flow and prevent complications.

 

Choice C rationale

 

Wearing a tight-fitting bra can restrict milk flow and exacerbate mastitis. A well-fitting, supportive bra is recommended to avoid further complications.

 

Choice D rationale

 

Limiting the time the infant nurses on each breast can lead to incomplete emptying and increase the risk of mastitis. It is important to ensure the breasts are fully emptied to prevent infection.


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Correct Answer is C

Explanation

Choice A rationale

Within 2 days after delivery is not the typical timeframe for breast milk to come in. Colostrum, the first milk, is produced immediately after birth, but mature milk usually comes in a few days later.

Choice B rationale

In about 10 days after delivery is too late for the onset of mature breast milk. Most women experience their milk coming in within the first week postpartum.

Choice C rationale

In 3 to 5 days after delivery is the correct response. This is the typical timeframe for the transition from colostrum to mature milk. During this period, the breasts may feel fuller and heavier as milk production increases.

Choice D rationale

In 6 to 8 days after delivery is later than the usual timeframe for breast milk to come in. While there can be some variation, most women experience their milk coming in within 3 to 5 days postpartum.

Correct Answer is D

Explanation

Choice A rationale

Rho(D) immune globulin is not indicated if both the client and the newborn are Rh positive. There is no risk of Rh incompatibility in this scenario.

Choice B rationale

Similarly, if both the client and the newborn are Rh positive, there is no need for Rho(D) immune globulin.

Choice C rationale

If both the client and the newborn are Rh negative, there is no risk of Rh incompatibility, and Rho(D) immune globulin is not needed.

Choice D rationale

Rho(D) immune globulin is indicated when the client is Rh negative and the newborn is Rh positive. This prevents the development of Rh antibodies in the client, which could affect future pregnancies.

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