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
Explanation
Choice A reason: Lethargy and hypotonia are concerning symptoms that indicate a significant decrease in muscle tone and alertness, which can be associated with various medical conditions. However, they may not require immediate intervention compared to a critically low heart rate.
Choice B reason: Elastic skin turgor is generally a normal finding, indicating good hydration status and skin elasticity. It does not require urgent attention.
Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a paediatric patient, indicating bradycardia. This requires immediate attention and intervention to ensure the patient's cardiovascular stability.
Choice D reason: A blood pressure of 100/54 mmHg is within a normal range for many paediatric patients and does not indicate an immediate emergency.
Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A reason: The Diphtheria, Tetanus, and Pertussis (DTaP) vaccine is recommended for infants at 2, 4, and 6 months of age. It helps protect against three serious bacterial infections: diphtheria, tetanus, and pertussis.
Choice B reason: The Hepatitis B vaccine is usually administered at birth, 1-2 months, and 6-18 months. The 4-month visit may include this vaccine if it is part of the catch-up schedule or combined with other vaccines.
Choice C reason: The Inactivated Polio Vaccine (IPV) is given at 2, 4, and 6-18 months of age to protect against poliovirus, which can cause paralysis and other severe health issues.
Choice D reason: The Pneumococcal 13 Vaccine (PCV13) protects against 13 types of pneumococcal bacteria, which can cause serious infections like pneumonia, meningitis, and sepsis. It is typically given at 2, 4, and 6 months of age.
Choice E reason: The Haemophilus Influenzae type B (Hib) vaccine is administered at 2, 4, and 6 months of age to protect against infections caused by Hib bacteria, such as meningitis, pneumonia, and epiglottitis.
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