A patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?
Manually express colostrum as necessary.
Apply hot compresses to the breasts.
Massage the breast tissue surrounding the areola.
Wear a supportive bra.
The Correct Answer is D
The correct answer is choice D. Wear a supportive bra. This will help suppress lactation and reduce the discomfort of engorgement.
The other choices are wrong because:
• Choice A. Manually express colostrum as necessary. This will stimulate milk production and prolong engorgement.
• Choice B. Apply hot compresses to the breasts. This will increase blood flow and swelling in the breasts and worsen engorgement.
• Choice C. Massage the breast tissue surrounding the areola. This will also stimulate milk production and prolong engorgement.
Normal ranges for breast engorgement are not applicable as it is a subjective experience that varies among women. However, some signs of engorgement include firm, tender, swollen breasts, flat or inverted nipples, and low-grade fever. Engorgement usually resolves within 24 to 36 hours after it begins.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.
Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.
Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.
It usually resolves within 24 to 48 hours after birth.
Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.
It usually disappears by 6 months of age.
Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.
It usually fades by 4 months of age.
Correct Answer is D
Explanation
The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood.This is apositive sign of pregnancythat can only be attributed to a fetus.hCG is a hormone produced by the placenta that can be detected in blood or urine tests.
Choice A. Quickening.This is apresumptive sign of pregnancythat is based on the woman’s report of feeling fetal movements in her lower abdomen.This can occur at 16 weeks for second time moms and around 20 weeks for first time moms.However, this sign is not conclusive as other conditions can cause similar sensations.
Choice B. Uterine enlargement.This is aprobable sign of pregnancythat can be observed by the nurse or doctor through palpation.However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.
Choice C. Urinary frequency.This is apresumptive sign of pregnancythat is based on the woman’s report of needing to urinate more often than usual.This can be caused by hormonal changes and increased blood volume during pregnancy.However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.
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