A client who is breastfeeding experiences engorgement on the 4th postpartum day. The nurse should explain to the client that engorgement is the result of:
a. a blocked milk duct
b. milk stasis that has resulted in inflammation of the breast
c. the breasts beginning to fill with colostrum
d. vasocongestion of breast tissues as milk production begins
D
Engorgement of the breasts occurs at day 3 or 4 . If the breasts are not emptied, the engorgement will spontaneously disappear and discomfort will decrease in 24 to 48 hours. This is a result of vasocongestion of breast tissues as milk production begins or "let down" occurs.
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Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from
a. infection. b. dysrhythmias with cardiac arrest. c. hypovolemic shock and renal failure. d. adrenal failure.
The emergency department nurse realizes that the husband of a client appears increasingly irritable
as he waits. Interventions to prevent escalation of anger would include a. periodically updating the husband about what is being done for his wife. b. explaining that his wife will have to wait because clients are treated in order of need. c. asking that he relax, explaining that his wife's condition is not life threatening. d. suggesting that he return home and have the physician call with an update in 3 hours.
The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?
a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour
An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted
Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of: a. RDS. b. PIVH. c. BPD. d. ROP.