A breastfeeding woman develops engorged breasts at 3 days postpartum.
What action would help this woman achieve her goal of reducing the engorgement?

Rationale for Correct Condition

Subinvolution refers to delayed uterine involution, often due to retained placental fragments or infection. The boggy uterus, excessive lochia, and passage of clots are hallmark signs. The history of postpartum hemorrhage increases risk, and fundal tenderness suggests uterine atony rather than infection or hematoma formation.

Rationale for Correct Actions

Oxytocin enhances uterine contractions to reduce bleeding and facilitate involution by increasing myometrial tone. Methylergonovine is a potent uterotonic that further supports contraction, decreasing hemorrhage risk, but must be used cautiously in hypertensive patients.

Rationale for Correct Parameters

Saturated perineal pads track blood loss severity, guiding interventions for ongoing hemorrhage. Excessive bleeding may require further medical management. Hemoglobin and hematocrit assess for anemia due to blood loss, guiding transfusion decisions if needed.

Rationale for Incorrect Conditions

Postpartum preeclampsia presents with hypertension and proteinuria, not uterine atony. Perineal hematoma manifests as localized swelling with severe perineal pain, which is absent here. Thrombophlebitis involves unilateral extremity swelling and pain, not fundal tenderness or abnormal lochia.

Rationale for Incorrect Actions

Ice packs to the perineum manage hematomas, not uterine atony. Anticoagulants are used for thromboembolic prevention, not postpartum bleeding. Quiet environment is relevant for preeclampsia, not uterine subinvolution.

Rationale for Incorrect Parameters

Seizures are relevant to preeclampsia, not uterine subinvolution. Calf circumference is monitored for thrombophlebitis, which is absent here. Rectal pain is not an expected indicator of uterine involution status.

Step 1: Heart rate of 110/min scores 2 points (normal heart rate >100).

Step 2: Slow weak cry scores 1 point (good strong cry scores 2, no cry scores 0).

Step 3: Some flexion of extremities scores 1 point (active movement scores 2, limp scores 0).

Step 4: Grimace in response to suctioning scores 1 point (coughing or sneezing scores 2, no response scores 0).

Step 5: Body pink, blue extremities scores 1 point (completely pink scores 2, completely blue or pale scores 0).

Step 6: Total Apgar score is the sum of the scores from each category: 2 + 1 + 1 + 1 + 2 = 7. Final calculated answer: 7.