A woman gave birth 48 hours ago to a healthy infant girl.
She has decided to bottle feed.
During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.
Which guidance should the nurse provide to the client at this time?
Express small amounts of milk from the breasts to relieve the pressure.
Wearing a loose-fitting bra to prevent nipple irritation.
Apply cold packs to the breasts for comfort.
Run warm water on her breasts during a shower.
The Correct Answer is C
Choice A rationale
Expressing milk when bottle-feeding can stimulate further milk production, which would exacerbate the engorgement and discomfort. The goal is to discourage milk production.
Choice B rationale
While a supportive bra is generally recommended for comfort, a loose-fitting bra might not provide adequate support to reduce swelling and discomfort associated with engorgement. A firm, supportive bra is usually advised.
Choice C rationale
Cold packs cause vasoconstriction, which helps to reduce blood flow to the breasts, thereby decreasing swelling, inflammation, and pain associated with engorgement. This provides symptomatic relief without stimulating milk production.
Choice D rationale
Warm water can stimulate milk flow, which is counterproductive when trying to suppress lactation in a bottle-feeding mother experiencing engorgement. Warmth increases blood flow and can worsen swelling and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
G represents gravida, the total number of pregnancies, including the current one (2). T represents term births, the number of pregnancies delivered at 37 weeks gestation or later (1). P represents preterm births, the number of pregnancies delivered between 20 and 36 weeks gestation (0). A represents abortions, the number of pregnancies ending before 20 weeks gestation (0). L represents living children (1).
Choice B rationale
This option incorrectly states L as 2. The client has one living child from the previous pregnancy.
Choice C rationale
This option incorrectly states P as 1. The client's previous pregnancy was delivered at 38 weeks, which is considered a term birth, not preterm.
Choice D rationale
This option incorrectly states G as 3. The client is currently pregnant with twins, making this her second pregnancy in total.
Correct Answer is B
Explanation
Choice A rationale
Cocaine is a stimulant that typically causes fetal tachycardia (an elevated fetal heart rate) due to its sympathomimetic effects, increasing maternal and subsequently fetal heart rate and blood pressure. It does not usually lead to fetal bradycardia.
Choice B rationale
Prolonged umbilical cord compression can lead to fetal bradycardia because it restricts oxygenated blood flow to the fetus. The baroreceptors in the fetus respond to decreased oxygen by slowing the heart rate in an attempt to conserve oxygen and maintain perfusion to vital organs.
Choice C rationale
Fetal anemia, a decrease in red blood cell count, can lead to fetal tachycardia as the heart attempts to compensate for reduced oxygen-carrying capacity by increasing cardiac output. Bradycardia is not a typical initial response to fetal anemia.
Choice D rationale
Terbutaline is a tocolytic medication used to relax the smooth muscle of the uterus and prevent preterm labor. Its side effects often include maternal and fetal tachycardia due to its beta-adrenergic agonist activity.
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