A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

"I'll feed my baby every 2 hours."

"I'll apply cold compresses 20 minutes before each feeding."

"I'll try drinking an herbal tea to reduce the engorgement."

"I'll let my baby drain one breast at each feeding."

Answer and Explanation

The Correct Answer is A

Feeding the baby every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement by reducing milk stasis and promoting milk production regulation.

Applying cold compresses before feeding may temporarily reduce discomfort but does not address the underlying cause of engorgement or promote milk removal.

Drinking herbal tea is not proven to effectively reduce breast engorgement, and it is important for the client to focus on frequent breastfeeding or pumping to alleviate engorgement.

Allowing the baby to drain one breast at each feeding may lead to uneven milk production and exacerbate engorgement. It is important for the client to offer both breasts at each feeding to ensure adequate milk removal from both breasts.

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Correct Answer is D

Explanation

A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.

A. Ventrogluteal B. Vastus lateralis C. Dorso-gluteal D. Deltoid

Correct Answer is B

Explanation

A. The ventrogluteal site can be used for IM injections in older infants but is not typically used in newborns.
B. The vastus lateralis muscle is the preferred site for IM injections in newborns due to its size and accessibility.
C. The dorso-gluteal site is not recommended for IM injections in infants due to the risk of injury to the sciatic nerve.
D. The deltoid muscle is not typically used for IM injections in newborns due to its small size and less developed musculature.

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A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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