The nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast en-gorgement
The nurse provides which instructions to the client regarding relief of the engorge-ment? Select all that apply. 1. Feed the infant at least every 2 hours for 15 to 20 minutes on each side.
2. Avoid breast-feeding during the time of breast engorgement.
3. Apply moist heat to both breasts for about 20 minutes before a feeding.
4. Massage the breasts gently during a feeding, from the outer areas to the nipples.
5. Wear a supportive bra between feedings.
1, 3, 4, 5
Rationale: During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gen-tly from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The cli-ent also should be instructed to wear a supportive bra between feedings.
You might also like to view...
A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection."
The client states, "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would receive priority for nursing intervention? A) Risk for Infection B) Ineffective Breathing Pattern C) Disturbed Sleep Pattern D) Anxiety
Which of the following should the nurse encourage to help prevent and control community-acquired infections?
A) Diet and exercise regimen C) Childhood immunizations B) Reduced smoking D) Regular checkups
An older adult patient who is to begin taking imipramine [Tofranil] asks the nurse when the drug should be taken. The nurse will instruct the patient to:
a. divide the daily dose into two equal doses 12 hours apart. b. take the entire dose at bedtime to minim-ize sedative effects. c. take the medication once daily in the late afternoon. d. take the medication once daily in the morning.
Clients receiving local anesthetic agents frequently experience:
a. fetal bradycardia, if pregnant. c. central nervous system stimulation. b. allergic reactions. d. itching in the area of anesthesia.