A nurse is caring for a client who is 5 hours postpartum following a successful vaginal birth of twins. The nurse should recognize that this client is at increased risk for which of the following postpartum complications?
Mastitis.
Uterine infection.
Uterine atony.
Retained placental fragments.
The Correct Answer is C
Choice A rationale
Mastitis is an infection of the breast tissue that results in breast pain, swelling, warmth, and redness. It is more common in breastfeeding women and typically occurs when bacteria enter the breast tissue through a cracked or sore nipple. While it is a postpartum complication, it is not specifically associated with the delivery of twins.
Choice B rationale
Uterine infection, also known as endometritis, is an infection of the uterine lining. It can occur after childbirth, especially if there were complications such as prolonged labor, multiple vaginal exams, or manual removal of the placenta. However, it is not specifically associated with the delivery of twins.
Choice C rationale
Uterine atony is the most common cause of postpartum hemorrhage. It occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. The risk of uterine atony is higher in cases of overdistension of the uterus, such as with multiple gestations (twins), polyhydramnios, or a large baby. Therefore, a client who has delivered twins is at increased risk for uterine atony.
Choice D rationale
Retained placental fragments occur when parts of the placenta remain in the uterus after childbirth. This can lead to postpartum hemorrhage and infection. While it is a potential complication, it is not specifically associated with the delivery of twins.
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Correct Answer is A
Explanation
Choice A rationale
Ensuring the newborn has a successful latch is crucial for preventing and treating sore and cracked nipples. A poor latch can cause nipple trauma and pain.
Choice B rationale
Increasing the length of time between feedings is not recommended as it can lead to engorgement and further complications. Frequent breastfeeding helps maintain milk supply and prevents issues like mastitis.
Choice C rationale
Applying mineral oil to the nipples is not recommended. Instead, using expressed breast milk or medical-grade lanolin can promote healing.
Choice D rationale
Keeping the nipples covered between breastfeeding sessions is not necessary and can sometimes exacerbate the problem. Allowing the nipples to air dry or using hydrogel pads can be more beneficial.
Correct Answer is A
Explanation
Choice A rationale
The client is exhibiting expected assessment findings. Three days postpartum, it is normal for the fundus to be three fingerbreadths below the umbilicus, lochia rubra to be light, and the breasts to be full and warm to palpation without evidence of redness or pain. These findings indicate that the uterus is involuting properly, and the breasts are producing milk for breastfeeding.
Choice B rationale
The client is not exhibiting indications of mastitis. Mastitis is characterized by breast tenderness, redness, warmth, and pain, often accompanied by fever and flu-like symptoms. The absence of these symptoms suggests that the client does not have mastitis.
Choice C rationale
There is no indication that the client should be advised to remove her nursing bra. A well-fitting nursing bra can provide support and comfort during breastfeeding. The client should continue to wear a nursing bra as needed.
Choice D rationale
There is no indication that the client should be advised to stop breastfeeding. The assessment findings suggest that breastfeeding is going well, and the client should be encouraged to continue breastfeeding to provide optimal nutrition for the infant.