During a home care visit, the new mother complains of breast ...

[justinmsk]

During a home care visit, the new mother complains of breast engorgement. Which intervention is most appropriate for recommendation by the home care nurse?
 
  1. Apply an ice compress to your breast before nursing.
  2. Encourage your baby to suckle for an average of 5 minutes per feeding.
  3. Apply warm compresses to your breast after you finish feeding your baby.
  4. When you aren't nursing, wear a well-fitted nursing bra at all times, even when you sleep.

Question 2

The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours.
 
  Her fundus was boggy, and firmed with massage to 1 FB  U, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 110. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this patient?
  1. Acute pain related to perineal trauma
  2. Risk for deficient fluid volume related to uterine bleeding and nausea
  3. Readiness for enhanced family coping
  4. Knowledge deficit related to newborn care

[tashiedavis420]

Answer to Question 1

Correct Answer: 4
Rationale 1: Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother.
Rationale 2: For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours.
Rationale 3: Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother.
Rationale 4: The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.

Answer to Question 2

Correct Answer: 2
Rationale 1: Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit.
Rationale 2: Adequate fluid volume is a critical Physiological need; therefore, this is the highest-priority nursing diagnosis.
Rationale 3: Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit.
Rationale 4: Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the Physiological need for adequate fluid volume.