A nurse is caring for a client with the nursing diagnosis of acute pain related to breast engorgement.
Which interventions should the nurse include in the plan of care?
Apply warm compresses to the breasts before breastfeeding.
Advise the client to limit fluid intake to reduce milk production.
Apply cold compresses to the breasts after breastfeeding.
Instruct the client to breastfeed frequently or pump milk regularly.
Encourage the client to wear a tight-fitting bra throughout the day.
The Correct Answer is A
Choice A rationale
Applying warm compresses before breastfeeding promotes vasodilation, increasing blood flow to the breast tissue. This facilitates milk let-down by relaxing the smooth muscles around the alveoli and ducts, making it easier for the infant to latch and nurse effectively, thereby relieving engorgement and associated pain.
Choice B rationale
Limiting fluid intake is contraindicated for breast engorgement. Adequate hydration is essential for maintaining milk production. Reducing fluids can lead to dehydration and potentially decrease milk supply, exacerbating engorgement and discomfort rather than alleviating it.
Choice C rationale
Applying cold compresses after breastfeeding helps to reduce inflammation and swelling in the breast tissue. The cold temperature causes vasoconstriction, which decreases blood flow and can minimize discomfort and engorgement by reducing tissue edema.
Choice D rationale
Frequent breastfeeding or regular pumping helps to remove milk from the breasts, which is the primary intervention for relieving engorgement. Regular emptying prevents milk from accumulating in the ducts and alveoli, reducing pressure and pain. This also helps establish and maintain milk supply.
Choice E rationale
Wearing a tight-fitting bra can restrict milk flow and increase pressure on the breast tissue, potentially worsening engorgement and causing discomfort. A supportive but not restrictive bra is recommended to provide comfort without impeding circulation or milk ducts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While magnesium sulfate can sometimes lead to a mild diuresis, its primary therapeutic effect in severe preeclampsia is not a direct reduction in swelling and fluid retention. These symptoms are more effectively managed by addressing the underlying hypertension and potential fluid overload through other interventions.
Choice B rationale
Magnesium sulfate is primarily used as an anticonvulsant and to lower blood pressure in severe preeclampsia. While it might indirectly alleviate some discomfort associated with preeclampsia, a direct reduction in pain and headaches is not the primary indicator of its therapeutic effectiveness.
Choice C rationale
Magnesium sulfate does have antihypertensive properties and can help lower blood pressure in severe preeclampsia. However, its most critical role is in preventing seizures. Therefore, monitoring blood pressure alone is not the most appropriate way to determine if the medication is working effectively in preventing seizures. Normal blood pressure is typically less than 120/80 mmHg.
Choice D rationale
Magnesium sulfate is administered in severe preeclampsia primarily to prevent seizures and may also have a relaxing effect on smooth muscles, which can improve hyperreflexia. A decrease in seizure activity and the normalization of deep tendon reflexes (normal range is 2+) are key indicators that the magnesium sulfate is achieving its therapeutic goals.
Correct Answer is B
Explanation
Choice A rationale
The fetal heart indeed pumps blood to both the placenta, where oxygen and nutrients are obtained, and to the developing organs, which require these substances for growth and function. This dual circulation is essential for fetal development. The normal circulatory pattern ensures that oxygenated blood returns from the placenta to nourish the fetal tissues, while deoxygenated blood is transported back to the placenta for gas exchange.
Choice B rationale
Maternal and fetal blood do not mix under normal physiological conditions. The exchange of gases, nutrients, and waste products occurs across the placental barrier, which consists of fetal and maternal tissues but keeps their bloodstreams separate. This separation prevents potential immune reactions and maintains distinct circulatory systems for the mother and the fetus.
Choice C rationale
The placenta serves as the vital site for gas exchange in the fetus. Oxygen and carbon dioxide are exchanged between the maternal and fetal blood across the placental membranes via diffusion. Oxygen-rich blood from the mother is delivered to the fetus, while carbon dioxide, a waste product of fetal metabolism, moves from the fetus to the mother for elimination.
Choice D rationale
The umbilical arteries are responsible for carrying deoxygenated blood and waste products from the fetus to the placenta. This deoxygenated blood is then oxygenated and cleared of waste at the placenta before returning to the fetus via the umbilical vein. This flow pattern is crucial for maintaining the fetal environment and supporting its development.
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