A nurse is collecting data from a client who is 18 hr postpartum. Which of the following findings require the nurse to intervene?
Fundus located to right of umbilicus.
Temperature 37.8° C (100° F).
Deep tendon reflexes 2+.
Moderate amount of lochia rubra.
The Correct Answer is A
Choice A rationale
Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.
Choice B rationale
A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.
Choice C rationale
Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.
Choice D rationale
A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.
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Correct Answer is B
Explanation
Choice A rationale
Wearing an underwire bra is not recommended for clients with inverted nipples as it can cause discomfort and restrict milk flow. Proper support without constriction is essential.
Choice B rationale
Placing breast shells in the client's bra helps to draw out inverted nipples by applying gentle pressure, making breastfeeding easier. They also protect the nipples from friction and irritation.
Choice C rationale
Providing plastic-lined breast pads may prevent leakage, but they do not address the issue of inverted nipples. Proper nipple preparation is essential for effective breastfeeding.
Choice D rationale
Applying breast cream regularly might keep the skin hydrated, but it does not help to correct the inversion of the nipples. Mechanical aids like breast shells are more effective.
Correct Answer is B
Explanation
Choice A rationale
Carrots, while nutritious and rich in vitamins, are not a significant source of iron. They provide fiber and beta-carotene but do not meet the increased iron needs during pregnancy.
Choice B rationale
Chicken breast is an excellent source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Consuming chicken breast helps in meeting the increased iron requirements during pregnancy.
Choice C rationale
Apples are healthy and provide essential nutrients and fiber but are not a significant source of iron. They contribute to overall well-being but do not address the specific need for increased iron intake.
Choice D rationale
Feta cheese is a good source of calcium and protein but not iron. While it contributes to nutritional intake during pregnancy, it does not help in meeting the increased iron needs.