A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
The client is exhibiting early indications of mastitis.
Additional interventions are not indicated at this time.
The client should be advised to remove her nursing bra.
Application of a heating pad to the breasts is indicated.
The Correct Answer is B
Choice a reason:
Mastitis is an infection of the breast tissue that results in pain, swelling, warmth, and redness. The symptoms of mastitis typically include breast tenderness, redness on the skin, breast pain, and sometimes fever and malaise. While the client's breasts are described as hard and warm, which could be associated with mastitis, the absence of other key symptoms such as fever or flu-like symptoms suggests that mastitis may not be the issue here.
Choice b reason:
Three days postpartum, it is normal for the fundus to be below the umbilicus and for lochia rubra to be present. The hardness and warmth of the breasts could be due to milk coming in, which is also a normal postpartum change. Without additional symptoms of concern, such as fever, severe pain, or signs of infection, it is reasonable to conclude that no additional interventions are required at this time.
Choice c reason:
Removing a nursing bra can provide comfort, especially if it is too tight and contributing to breast engorgement or clogged ducts. However, there is no indication that the client's nursing bra is causing an issue. Nursing bras are designed to support the breasts during breastfeeding and typically do not need to be removed unless they are causing specific problems.
Choice d reason:
Applying a heating pad can help with milk let-down and relieve discomfort from engorgement or clogged ducts. However, since the client is not exhibiting signs of mastitis or severe engorgement, and the warmth of the breasts may be due to normal postpartum changes, the application of a heating pad is not necessarily indicated at this time.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While vaginal bleeding can be associated with ectopic pregnancy, it is not typically characterized by a large amount. The bleeding is often described as spotting or light bleeding. A large amount of vaginal bleeding is more indicative of other conditions, such as a miscarriage or placental issues.
Choice B reason:
Unilateral, cramp-like abdominal pain is one of the hallmark signs of an ectopic pregnancy. This pain is usually felt on one side of the abdomen and can vary from mild to severe. It occurs due to the embryo implanting outside the uterus, most commonly in one of the fallopian tubes, which can cause irritation and discomfort as it grows.
Choice C reason:
Uterine enlargement greater than expected for gestational age is not a symptom of ectopic pregnancy. In fact, the uterus may not enlarge as much as expected because the embryo is not growing inside it. Ectopic pregnancies are often associated with a smaller-than-expected uterus for the gestational age.
Choice D reason:
Severe nausea and vomiting are not specific to ectopic pregnancy and can occur with any pregnancy. However, if these symptoms are accompanied by other signs of ectopic pregnancy, such as abdominal pain and vaginal bleeding, they may support the diagnosis.
Correct Answer is B
Explanation
Choice A reason:
Notifying the provider of the findings is important, but it is not the immediate priority. The provider should be informed after initial measures to stabilize the client's condition have been taken.
Choice B reason:
Positioning the client with one hip elevated, also known as the lateral or left-lateral position, is the priority action. This position can help improve blood flow and potentially increase the maternal blood pressure, which is critically low at 92/54 mm Hg. It also helps to optimize uteroplacental perfusion, which is essential for the well-being of both the mother and the fetus.
Choice C reason:
Having the client void can be helpful in preventing bladder distention, which can interfere with labor progress. However, it is not the priority action when the client's blood pressure is significantly low.
Choice D reason:
Asking the client if she needs pain medication is an important part of comfort care during labor. However, addressing the client's low blood pressure is a more immediate concern to prevent potential complications for both the mother and the fetus.
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