A nurse is planning care for a client who is breastfeeding 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,E

A. Instruct the client to wash their hands prior to breastfeeding: Correct. Proper hand hygiene helps to prevent the spread of infection, which is important for a client with mastitis. Washing hands before breastfeeding is a crucial infection control measure.

B. Teach the client about proper latching-on techniques: Correct. Proper latching-on techniques can help prevent further complications and ensure effective milk removal, which can help in managing mastitis and preventing recurrence.

C. Encourage the client to alternate breastfeeding with formula feeding: Incorrect. Breastfeeding should continue as usual because it helps to empty the breast and relieve engorgement, which is crucial for managing mastitis. Formula feeding could exacerbate the problem by increasing engorgement.

D. Instruct the client to avoid using a breast pump: Incorrect. Using a breast pump can be beneficial for managing mastitis by helping to relieve engorgement and ensure proper milk drainage. The pump should be used correctly and hygienically.

E. Encourage the client to allow their nipples to air dry after feedings: Correct. Allowing the nipples to air dry helps prevent further irritation and infection. It is important for maintaining skin integrity and comfort during mastitis.

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Correct Answer is A

Explanation

A. Respiratory rate 11/min: Correct. A respiratory rate of 11/min is below the normal range and could indicate magnesium sulfate toxicity, which can depress respiratory function. This finding requires prompt reporting to prevent further complications.

B. Deep tendon reflexes 2+: Incorrect. Deep tendon reflexes of 2+ are within the normal range and are not indicative of magnesium sulfate toxicity. Normal reflexes suggest that the magnesium level is likely within the therapeutic range.

C. Urine output 30 mL/hr: Incorrect. While urine output should be monitored in clients receiving magnesium sulfate, 30 mL/hr is on the lower end of normal but not necessarily an immediate cause for concern unless it is persistently low or accompanied by other symptoms.

D. Blood pressure 100/62 mm Hg: Incorrect. This blood pressure reading is within the acceptable range for a pregnant client on magnesium sulfate. Magnesium sulfate is used to prevent seizures and does not typically affect blood pressure in this manner.

A. Periodic tingling of fingers B. Absence of clonus C. Leg cramps D. Blurred vision

Correct Answer is D

Explanation

A. Incorrect. Periodic tingling of fingers is not typically considered a sign of a serious prenatal complication. It can be related to normal pregnancy changes such as carpal tunnel syndrome.

B. Incorrect. The absence of clonus is not indicative of a complication. Clonus, or the lack thereof, is a normal finding in the absence of significant neurological issues.

C. Incorrect. Leg cramps are a common issue during pregnancy and usually not a sign of a severe complication.

D. Correct. Blurred vision can be a sign of preeclampsia or other significant prenatal complications, and should be evaluated further to ensure proper management and safety for both the mother and fetus.

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A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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