A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding.Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate.Her breasts feel hard and warm.Which of the following recommendations should the nurse give the client?
Obtain a prescription for an antibiotic.
Express milk from both breasts.
Wear a nipple shield.
Apply a heating pad to her breasts.
The Correct Answer is B
Choice A rationale
Obtaining a prescription for an antibiotic is not the first recommendation for a client who is 3 days postpartum and breastfeeding with hard and warm breasts. Antibiotics are typically prescribed if there is a confirmed infection, such as mastitis, which is characterized by symptoms like fever, chills, and flu-like symptoms. In this case, the client is experiencing normal postpartum breast engorgement, which does not require antibiotics.
Choice B rationale
Expressing milk from both breasts is the correct recommendation. Breast engorgement is common in the early postpartum period as the milk comes in. Expressing milk, either by breastfeeding frequently or using a breast pump, helps to relieve the fullness, reduce discomfort, and maintain milk production.
Choice C rationale
Wearing a nipple shield is not recommended for breast engorgement. Nipple shields are typically used for issues like latch difficulties or sore nipples, not for relieving engorgement. Using a nipple shield without proper guidance can potentially interfere with milk transfer and breastfeeding success.
Choice D rationale
Applying a heating pad to the breasts is not recommended for engorgement. Heat can increase blood flow and exacerbate swelling. Instead, cold compresses or cold cabbage leaves are often recommended to reduce swelling and discomfort associated with engorgement.
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Correct Answer is B
Explanation
Choice B rationale
A heart rate of 110/min is a sign of tachycardia, which can indicate a postpartum complication such as infection, hemorrhage, or other underlying conditions. Tachycardia requires immediate assessment and intervention.
Choice A rationale
Chills shortly following delivery can be a normal response to the body’s adjustment after childbirth and do not necessarily indicate a complication.
Choice C rationale
Urinary output of 3,000 mL/12 hr is high but can be a normal part of postpartum diuresis as the body eliminates excess fluid accumulated during pregnancy.
Choice D rationale
The fundus at the umbilicus level is a normal finding in the immediate postpartum period and does not indicate a complication.
Correct Answer is B
Explanation
Choice A rationale
Urinary tract infections (UTIs) are not typically associated with increased lochia. UTIs usually present with symptoms such as burning during urination, frequent urination, and lower abdominal pain.
Choice B rationale
Lochia can pool in the vagina while lying in bed, leading to a larger amount being expelled upon standing. This is a normal occurrence and not a cause for concern.
Choice C rationale
Retained fragments of the placenta can cause heavy bleeding and infection, but the sudden expulsion of a large amount of lochia upon standing is more likely due to pooling rather than retained placenta.
Choice D rationale
The amount of lochia typically decreases over time during the postpartum period. An increase in lochia is not expected and should be evaluated for other causes.