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 C
Explanation
Choice A rationale
A cervical or perineal laceration would typically result in continuous bleeding rather than a gush that stops. The uterus would also not be firm and midline if there were a significant laceration.
Choice B rationale
Abnormally excessive lochia rubra flow would be continuous and not stop after a gush. The uterus being firm and midline indicates that the bleeding is not excessive.
Choice C rationale
A normal postural discharge of lochia occurs when pooled blood in the vagina is expelled upon standing or changing position. This is common and expected in the postpartum period.
Choice D rationale
A vaginal hematoma would present with localized pain and swelling, and the bleeding would not stop suddenly. The uterus being firm and midline also indicates that a hematoma is unlikely.
Correct Answer is B
Explanation
Choice A rationale
Hemorrhage is not prevented by walking. Hemorrhage management involves monitoring and medical interventions, not ambulation.
Choice B rationale
Walking helps prevent blood clots by promoting circulation. Postoperative patients are encouraged to ambulate early to reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism.
Choice C rationale
Breast engorgement is managed through breastfeeding or pumping, not walking. Ambulation does not directly affect breast engorgement.
Choice D rationale
Rupture of amniotic membranes is not relevant postpartum. This condition is related to labor and delivery, not postoperative care.