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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.

Choice B rationale:

A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.

Choice C rationale:

A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.

Choice D rationale:

The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.

A. Assist the client to a sitz bath. B. Assess the client's uterine tone. C. Encourage the client to breastfeed. D. Apply an ice pack to the client's perineum.

Correct Answer is B

Explanation

Choice A rationale:

Assisting the client to a sitz bath is not the priority action in this situation. The client has soaked two perineal pads in the past 30 minutes, indicating excessive bleeding, which requires immediate attention.

Choice B rationale:

Assessing the client's uterine tone is essential to determine if the uterus is contracting appropriately. Uterine atony, where the uterus fails to contract after childbirth, is a common cause of postpartum hemorrhage. Assessing the tone helps identify this issue and allows for timely interventions.

Choice C rationale:

Encouraging the client to breastfeed may have benefits such as promoting uterine contractions through oxytocin release. However, the priority in this scenario is addressing the potential postpartum hemorrhage.

Choice D rationale:

Applying an ice pack to the client's perineum may provide comfort, but it does not address the concerning symptom of excessive bleeding and potential postpartum hemorrhage.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?

Correct Answer is D

Explanation

A nurse is caring for a client who had a vaginal birth 2 hr ago and has soaked two perineal pads in the past 30 min. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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