A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)
Instruct the client to wash their hands prior to breastfeeding.
Teach the client about proper latching-on techniques.
Encourage the client to alternate breastfeeding with formula feeding.
Instruct the client to avoid using a breast pump.
Encourage the client to allow their nipples to air dry after feedings.
Correct Answer : A,B,E
Choice A rationale:
Instructing the client to wash their hands before breastfeeding helps prevent the transmission of infection to the breast and the baby.
Choice B rationale:
Teaching the client about proper latching-on techniques ensures effective breastfeeding, reduces the risk of nipple damage, and promotes comfort for both the client and the baby.
Choice C rationale:
Encouraging the client to alternate breastfeeding with formula feeding is not recommended for a client with mastitis. Mastitis is an inflammation of the breast tissue often caused by bacterial infection, and continuing breastfeeding helps to clear the infection and maintain milk supply.
Choice D rationale:
Instructing the client to avoid using a breast pump is not necessary in this situation. Breastfeeding and pumping can continue to help drain the breast adequately, which is essential for resolving mastitis.
Choice E rationale:
Encouraging the client to allow their nipples to air dry after feedings helps promote healing and prevents further irritation to the nipples.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. The client should receive Rh(D) immune globulin (RhoGAM) if they are Rh-negative and their partner's Rh status is unknown or Rh-positive. This prevents the development of Rh antibodies in the mother's blood, which could be harmful in future pregnancies if the baby is Rh-positive.
Choice B rationale:
This statement is incorrect. Rh(D) immune globulin is administered to an Rh-negative mother within 72 hours after delivery if the baby is Rh-positive. This is done to prevent the mother from developing Rh antibodies that could affect subsequent pregnancies.
Choice C rationale:
This statement is incorrect. There is no restriction on receiving other immunizations after receiving Rh(D) immune globulin. The shot only protects against Rh incompatibility and does not interfere with other immunizations.
Choice D rationale:
This statement is correct. Rh(D) immune globulin can be given after birth to an Rh-negative mother with an Rh-positive baby. This helps protect the mother's future pregnancies from the potential harmful effects of Rh incompatibility.
Correct Answer is A
Explanation
The correct answer is A. Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.
Choice A reason: Applying an ice pack to the episiotomy site helps reduce swelling and provides pain relief. This is the standard care within the first 24 hours postpartum.
Choice B reason: A warm sitz bath is generally recommended after the first 24 hours following birth. It is not the best immediate action for unrelieved pain shortly after delivery.
Choice C reason: While maintaining cleanliness with a squeeze bottle of antiseptic solution is important for preventing infection, it does not provide the immediate pain relief needed for unrelieved episiotomy pain.
Choice D reason: Heat application, such as placing a hot pack, is not advised within the first 24 hours postpartum because it can increase the risk of swelling and bleeding.
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