A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding their newborn. Which of the following instructions should the nurse include in the teaching?
"You should wear a snug-fitting bra continuously for 72 hours."
"You should apply moist heat to your breasts four times per day."
"You should limit your fluid intake to 1 liter per day."
"You should manually express milk when engorgement occurs."
The Correct Answer is A
A. "You should wear a snug-fitting bra continuously for 72 hours": Wearing a snug-fitting bra continuously for 72 hours can help suppress lactation by providing support and reducing stimulation to the breasts. This can help prevent milk production and engorgement.
B. "You should apply moist heat to your breasts four times per day": Moist heat can stimulate milk production and should be avoided when trying to suppress lactation.
C. "You should limit your fluid intake to 1 liter per day": Adequate hydration is important for overall health, and limiting fluid intake to 1 liter per day is not advisable, especially postpartum when hydration needs may be higher.
D. "You should manually express milk when engorgement occurs": Manual expression of milk can stimulate milk production and should be avoided when attempting to suppress lactation. If engorgement occurs, cold compresses or ice packs can be used to reduce discomfort without stimulating milk production.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Abdominal distention: Abdominal distention is a classic sign of paralytic ileus, which is a temporary cessation of intestinal peristalsis. When peristalsis is impaired, gas and fluid accumulate in the intestines, leading to abdominal distention.
B. Watery stool: Watery stool is not typically associated with paralytic ileus. In paralytic ileus, bowel movements are usually absent or significantly reduced due to decreased or absent peristalsis, resulting in constipation rather than watery stool.
C. Dizziness: Dizziness is not a typical sign of paralytic ileus. While the underlying cause of paralytic ileus may lead to electrolyte imbalances, which can manifest as dizziness, it is not a direct symptom of paralytic ileus itself.
D. Oliguria: Oliguria, or decreased urine output, is not directly related to paralytic ileus. Paralytic ileus affects the gastrointestinal tract, leading to symptoms such as abdominal distention and constipation, but it does not directly affect urinary output.
Correct Answer is B
Explanation
A. Diaphoresis: Diaphoresis, or excessive sweating, is a common side effect of clozapine and may not necessarily indicate a need for immediate intervention. However, it should be documented and monitored for any changes.
B. Fever: Fever can be a sign of infection, which is a serious concern in clients taking clozapine due to the risk of agranulocytosis, a potentially life-threatening side effect characterized by a severe decrease in white blood cell count. Any signs of infection, including fever, should be reported promptly to the provider for further evaluation and management.
C. Polyuria: Polyuria, or excessive urination, is not typically associated with clozapine use and may be indicative of other underlying issues such as diabetes mellitus or diabetes insipidus. While it should be assessed and managed appropriately, it is not specifically related to clozapine administration and may not require immediate reporting to the provider.
D. Diarrhea: Diarrhea is a common gastrointestinal side effect of clozapine and may occur due to its effects on the gastrointestinal system. While persistent or severe diarrhea should be monitored and managed, it is not typically considered a serious adverse reaction that requires immediate reporting to the provider unless it is accompanied by other concerning symptoms.
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