The nurse is caring for a patient three days postpartum who is exclusively breastfeeding. Upon assessment, the patient has cracked nipples, engorged breasts, and a painful latch. What will the nurse include in the patient's plan of care? Select all that apply.
Ibuprofen.
Vigorous massage.
Cold compress.
Formula supplements.
Lactation consult.
Correct Answer : A,C,E
Choice A reason: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help relieve pain and reduce inflammation associated with cracked nipples and engorged breasts. It is commonly used to manage postpartum pain and can provide significant relief, making breastfeeding more comfortable for the patient.
Choice B reason: Vigorous massage is not recommended for engorged breasts as it can cause additional pain and may worsen the condition. Gentle massage may help in some cases, but vigorous massage can lead to tissue damage and further discomfort. The focus should be on gentle techniques to manage engorgement.
Choice C reason: Cold compresses are effective in reducing swelling and providing pain relief for engorged breasts. Applying cold packs to the breasts can help reduce inflammation and soothe discomfort, making it easier for the patient to breastfeed. Cold therapy is a simple and non-invasive method to manage engorgement and related symptoms.
Choice D reason: Formula supplements are generally not recommended as a first-line intervention for breastfeeding issues, especially when the goal is to promote exclusive breastfeeding. Introducing formula can interfere with milk supply and the breastfeeding process. Instead, addressing the underlying issues such as latch and nipple care is more appropriate.
Choice E reason: A lactation consult is an essential intervention for a patient experiencing breastfeeding difficulties. Lactation consultants are trained to provide support and guidance on breastfeeding techniques, including how to achieve a proper latch, manage engorgement, and care for cracked nipples. Their expertise can significantly improve the breastfeeding experience and help resolve common issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Placing the patient in a supine position is not recommended in cases of suspected partial placental abruption. The supine position can compress the inferior vena cava, reducing blood flow to the placenta and potentially worsening the condition. Instead, a lateral position is generally preferred to enhance blood flow.
Choice B reason: Encouraging oral intake is not a priority action in this scenario. In cases of suspected placental abruption, the patient may need to undergo emergency medical procedures, and maintaining an empty stomach is often advised to prevent aspiration if anaesthesia is required.
Choice C reason: Administering IV fluids is crucial in managing suspected partial placental abruption. This intervention helps maintain maternal blood pressure and ensures adequate blood flow to the placenta, which is essential for fatal well-being. IV fluids can also be vital in managing any potential blood loss.
Choice D reason: Evaluating fatal heart rate monitoring is essential to assess the foetus’s well-being. Continuous monitoring allows the healthcare team to detect any signs of fatal distress, which can guide further medical interventions and decision-making processes.
Choice E reason: Monitoring maternal pain is a critical component of managing suspected partial placental abruption. Pain assessment helps determine the severity of the abruption and the effectiveness of pain management strategies. It also provides valuable information about the patient's condition and the need for additional interventions.
Correct Answer is D
Explanation
Choice A reason: Saying two-word sentences is an expected developmental milestone for an 18-month-old child. At this age, children should begin combining two words to form simple sentences, such as "more juice" or "mama go." This indicates normal language development.
Choice B reason: Using a pincer grasp to eat Cheerio’s is a typical fine motor skill for an 18-month-old child. The ability to pick up small objects between the thumb and forefinger demonstrates proper development of fine motor skills and hand-eye coordination.
Choice C reason: Removing shoes and socks is a common developmental milestone for an 18-month-old child. This task shows growing independence and the ability to perform basic self-care activities, which is a sign of normal development.
Choice D reason: Preferring to use the right hand may suggest a developmental delay because children typically do not show a strong hand preference (left or right) until around the age of 2 to 3 years. Early hand dominance can be a sign of an underlying issue, such as asymmetry in muscle strength or neurological development. It is important to assess further if a child shows a strong preference for one hand at this early age.
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