A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information
... [Show More] should the nurse provide?
A. This feeling occurs during feeding with a breast infection.
B. This sensation occurs as breast milk moves to the nipple.
C. The baby does not have good latch-on.
D. The infant is not positioned correctly. B. This sensation occurs as breast milk moves to the nipple.
Rationale:
When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.
A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first?
A. Check the client's blood pressure.
B. Teach her to elevate her feet when sitting.
C. Obtain a 24-hour diet history to evaluate for the intake of salty foods.
D. Assess the fetal heart rate. A. Check the client's blood pressure.
Rationale:
The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal.
A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement?
A. Teach the client testicular self-examination (TSE).
B. Assess for the presence of blood in the urine.
C. Ask about scrotal pain or blood in the semen.
D. Inquire about a history of kidney stones. C. Ask about scrotal pain or blood in the semen.
Rationale:
Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine. [Show Less]