nurse is contributing to the plan of care for a client who is postpartum and has mastitis. Which of the following actions should the nurse plan to take?
Prepare the client for an abdominal sonogram.
Encourage the client to continue to breastfeed
Encourage the client to wear a bra that is loose fitting
Limit the client's daily fluid intake.
The Correct Answer is B
(A) Prepare the client for an abdominal sonogram:
An abdominal sonogram is not relevant for diagnosing or treating mastitis, which is an infection of the breast tissue. Mastitis typically requires assessment of the breast and possibly a breast ultrasound if an abscess is suspected, but not an abdominal sonogram.
(B) Encourage the client to continue to breastfeed:
Continuing to breastfeed is recommended for clients with mastitis. Breastfeeding helps to drain the breast and can speed up recovery. It also helps to prevent complications such as breast abscess and supports continued milk production.
(C) Encourage the client to wear a bra that is loose fitting:
While wearing a comfortable bra is important, a loose-fitting bra may not provide the necessary support for engorged or painful breasts. A well-fitting, supportive bra is usually recommended to provide comfort without being too tight, which can exacerbate symptoms.
(D) Limit the client's daily fluid intake:
Limiting fluid intake is not recommended and is not beneficial for treating mastitis. Adequate hydration is important for overall health and helps maintain milk supply. Encouraging the client to drink plenty of fluids is essential for recovery and continued breastfeeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) Assist the client to empty her bladder:
Emptying the bladder is an essential intervention, especially in laboring women with epidural anesthesia, as a full bladder can contribute to hypotension. However, in this scenario, the priority is to address the hypotension directly with fluid administration. After stabilizing the client's blood pressure, assisting with bladder emptying would be appropriate.
(B) Place the client in knee-chest position:
The knee-chest position is not typically indicated for managing hypotension. While this position can increase venous return to the heart and potentially increase blood pressure, it is not the initial intervention for hypotension associated with epidural anesthesia. Intravenous fluid administration is the primary intervention to increase blood pressure in this situation.
(C) Administer methylergonovine IM:
Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by causing uterine contractions. It is not indicated for the management of hypotension associated with epidural anesthesia during labor. Administering methylergonovine in this situation could potentially exacerbate hypotension and should be avoided.
(D) Give a bolus of lactated Ringer's:
The client's blood pressure is low (80/40 mm Hg), indicating hypotension. Hypotension can be a common side effect of epidural anesthesia during labor. Administering a bolus of intravenous fluids, such as lactated Ringer's solution, is the initial intervention to address hypotension. Fluid administration helps increase intravascular volume, improving blood pressure and perfusion to vital organs.
Correct Answer is D
Explanation
(A) Ask a parent to state the newborn's date of birth:
While asking a parent to state the newborn's date of birth may seem like a reasonable step, it relies on the parent's memory and verbal confirmation, which may not always be accurate. It's possible for a parent to forget or provide incorrect information, leading to potential identification errors.
(B) Check the newborn's footprint sheet with the medical record:
Footprint identification is a common practice in hospitals, but it may not always be feasible or practical during routine newborn transport to parents. Additionally, relying solely on footprints for identification may not be as reliable as comparing identification bands, as footprints can smudge or be difficult to match accurately.
(C) Request a parent to verify the newborn's name:
Asking a parent to verify the newborn's name relies on verbal confirmation, similar to option A. While it may provide some level of reassurance, it is not as reliable as comparing identification bands to confirm identity. Additionally, newborns may not yet have been formally named at the time of transport.
(D) Compare numbers on the newborn's band to the parent's band:
Comparing the identification numbers on the newborn's identification band with those on the parent's identification band is the most reliable method to confirm the newborn's identity. This process ensures that the newborn is matched with the correct parent(s) before handing over the infant. It helps prevent instances of newborn mix-up or abduction.
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