A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis.Which of the following responses should the nurse make?
Completely empty each breast at each feeding or use a pump.
Nurse the infant only on the unaffected breast until resolved.
Wear a tight-fitting bra until lactation has ceased.
Limit the amount of time the infant nurses on each breast.
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
Inserting a urinary catheter is not the first action to take when the fundus is displaced to the right of midline. The displacement is often due to a full bladder, and the client should be encouraged to void first.
Choice B rationale
Massaging the fundus is appropriate if the uterus is boggy, but in this case, the fundus is firm. The displacement is likely due to a full bladder.
Choice C rationale
Having the client urinate is the correct action. A full bladder can displace the uterus and prevent it from contracting properly, which can lead to postpartum hemorrhage.
Choice D rationale
Administering analgesia is not relevant to the issue of a displaced fundus. The priority is to address the cause of the displacement, which is likely a full bladder.
Correct Answer is D
Explanation
Choice D rationale
Assisting the client to void is the first action the nurse should take. A full bladder can cause the fundus to deviate to the right and become boggy. Voiding helps the uterus contract and return to its normal position.
Choice A rationale
Inserting an indwelling urinary catheter may be necessary if the client is unable to void, but it is not the first action.
Choice B rationale
Administering methylergometrine to the client is not the first action. This medication stimulates uterine contractions and can help reduce postpartum bleeding, but the initial step is to address the full bladder.
Choice C rationale
Obtaining a stat hemoglobin level is important if there is a concern for significant blood loss, but it is not the first action.