A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is not planning on breastfeeding. Which of the following statements by the client indicates she understood the teaching?
“I should pump out the milk when my breasts become engorged.”.
“I will not wear a bra throughout the day.”.
“I should apply hot packs to my breasts.”.
“I will avoid stimulation to my nipples.”.
The Correct Answer is D
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.
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Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale
A headache that is not relieved by hydration, rest, or over-the-counter medication can be a sign of postpartum preeclampsia, a serious condition that can occur after childbirth. Postpartum preeclampsia is characterized by high blood pressure and can lead to seizures, stroke, and other complications if not treated promptly.
Choice B rationale
Brownish red or pink lochia at 7 days postpartum is a normal finding. Lochia is the vaginal discharge that occurs after childbirth, and it typically changes color from bright red to pink or brownish red as the healing process progresses.
Choice C rationale
Chills and fever greater than 100.4°F (38.0°C) can indicate an infection, such as endometritis, which is an infection of the uterine lining. This condition requires prompt medical evaluation and treatment with antibiotics to prevent complications.
Choice D rationale
Feelings or thoughts of harming oneself or the infant are indicative of postpartum depression or postpartum psychosis, both of which are serious mental health conditions that require immediate attention and intervention from a healthcare provider.
Choice E rationale
Increased urinary output is a common postpartum finding as the body eliminates excess fluid retained during pregnancy. It is not typically a sign of a complication.
Choice F rationale
Redness, pain, or tenderness in the calf can be a sign of deep vein thrombosis (DVT), a blood clot that can occur in the legs. DVT is a serious condition that requires immediate medical evaluation and treatment to prevent the clot from traveling to the lungs and causing a pulmonary embolism.
Correct Answer is C
Explanation
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.