A nurse is caring for a client who is postpartum and finds the fundus firm and deviated to the left, lochia is rubra and scant. Based on these findings, which of the following actions should the nurse take?
Ask the client to rate her pain.
Encourage the client to perform Kegel exercises.
Assist the client to the bathroom to void.
Encourage the client to move to the left lateral position.
The Correct Answer is C
Choice A rationale
Asking the client to rate her pain is important for assessing discomfort, but it does not address the immediate issue of a deviated fundus. A deviated fundus often indicates a full bladder, which can impede uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
Encouraging the client to perform Kegel exercises is beneficial for pelvic floor strengthening but does not address the immediate concern of a deviated fundus. The priority is to ensure the uterus can contract properly.
Choice C rationale
Assisting the client to the bathroom to void is the correct action. A full bladder can displace the uterus, preventing it from contracting effectively and increasing the risk of hemorrhage. Voiding helps the uterus return to its proper position and function.
Choice D rationale
Encouraging the client to move to the left lateral position may provide comfort but does not address the underlying issue of a full bladder causing uterine displacement.
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Correct Answer is D
Explanation
Choice A rationale
Pumping out the milk when breasts become engorged can provide temporary relief, but it can also stimulate further milk production, leading to continued engorgement. This is not recommended for clients who are not planning to breastfeed.
Choice B rationale
Not wearing a bra throughout the day can lead to discomfort and inadequate support for engorged breasts. Wearing a supportive bra, such as a sports bra, can help alleviate discomfort and provide necessary support.
Choice C rationale
Applying hot packs to the breasts can increase blood flow and exacerbate engorgement. Cold packs or ice packs are recommended to reduce swelling and provide relief from discomfort.
Choice D rationale
Avoiding stimulation to the nipples is an effective measure to reduce milk production and alleviate breast engorgement. This includes avoiding activities that may stimulate the nipples, such as pumping or hand expressing milk.
Correct Answer is A
Explanation
Choice A rationale
Galactopoiesis is the process of lactation maintenance and is reliant on breast stimulation and milk removal. This stage involves the ongoing production of milk in response to the infant’s demand.
Choice B rationale
Lactogenesis II refers to the onset of copious milk secretion that occurs around 2-3 days postpartum. It is triggered by the withdrawal of progesterone following the delivery of the placenta.
Choice C rationale
Mammogenesis is the development of the mammary glands during pregnancy. It involves the growth and differentiation of the breast tissue in preparation for lactation.
Choice D rationale
Lactogenesis I refers to the initial stage of milk production that begins during pregnancy and continues through the early postpartum period. It is hormonally driven and prepares the breasts for lactation. .