ATI Nur 209 Maternal Newborn Proctored Exam
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ATI Nur 209 Maternal Newborn Proctored Exam
A nurse is caring for a client with the nursing diagnosis of acute pain related to breast engorgement.Which interventions should the nurse include in the plan of care?
Explanation
Choice A rationaleApplying warm compresses before breastfeeding promotes vasodilation, increasing blood flow to the breast tissue. This facilitates milk let-down by relaxing the smooth muscles around the alveoli and ducts, making it easier for the infant to latch and nurse effectively, thereby relieving engorgement and associated pain.Choice B rationaleLimiting fluid intake is contraindicated for breast engorgement. Adequate hydration is essential for maintaining milk production. Reducing fluids can lead to dehydration and potentially decrease milk supply, exacerbating engorgement and discomfort rather than alleviating it.Choice C rationaleApplying cold compresses after breastfeeding helps to reduce inflammation and swelling in the breast tissue. The cold temperature causes vasoconstriction, which decreases blood flow and can minimize discomfort and engorgement by reducing tissue edema.Choice D rationaleFrequent breastfeeding or regular pumping helps to remove milk from the breasts, which is the primary intervention for relieving engorgement. Regular emptying prevents milk from accumulating in the ducts and alveoli, reducing pressure and pain. This also helps establish and maintain milk supply.Choice E rationaleWearing a tight-fitting bra can restrict milk flow and increase pressure on the breast tissue, potentially worsening engorgement and causing discomfort. A supportive but not restrictive bra is recommended to provide comfort without impeding circulation or milk ducts.