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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Related Questions
Correct Answer is D
Explanation
Choice A reason:
A soft, edematous area on the scalp, often referred to as a cephalohematoma, is a common finding after vacuum-assisted deliveries. This is due to the suction applied during delivery and usually resolves without intervention. However, it should be monitored for any signs of increased swelling or jaundice as it can sometimes lead to hyperbilirubinemia.
Choice B reason:
The blue coloring of the hands and feet, known as acrocyanosis, is a normal finding in the first few days of life. It occurs due to the immature circulation in the newborn and typically resolves as the baby's circulation adapts to life outside the womb.
Choice C reason:
Facial edema can be present in newborns following a vacuum-assisted delivery due to the pressure applied during the procedure. It is usually transient and resolves within a few days. However, persistent or severe edema may warrant further evaluation.
Choice D reason:
Poor sucking is a significant finding that should be reported to the provider. Effective sucking is crucial for adequate nutrition and hydration in the newborn. Poor sucking can be a sign of neurological compromise or other issues that require immediate attention to ensure the baby can feed properly and thrive.
Correct Answer is D
Explanation
Choice a reason:
Temperature monitoring is important in preterm labor to detect infections or inflammations that could complicate the pregnancy. However, while maternal temperature is a vital sign that should be monitored, it is not the priority in this context. The priority is to assess the well-being of the fetus, which is directly indicated by the FHR.
Choice b reason:
Bowel sounds are assessed to ensure gastrointestinal function and to detect potential complications such as ileus or bowel obstruction. In the context of preterm labor, while bowel sounds are part of a comprehensive assessment, they are not the priority over fetal well-being and maternal respiratory status, especially when administering magnesium sulfate, which does not primarily affect gastrointestinal function.
Choice c reason:
Respiratory rate is a critical assessment when administering magnesium sulfate due to the risk of respiratory depression as a side effect of the medication. It is essential to monitor because maternal oxygenation directly affects fetal oxygenation. However, the FHR is a more direct measure of fetal distress and therefore takes priority in this specific assessment.
Choice d reason:
Fetal heart rate (FHR) monitoring is the priority nursing assessment when administering magnesium sulfate IV to a client in preterm labor. Magnesium sulfate can affect uterine contractions and, by extension, fetal oxygenation and well-being. FHR is the most direct indicator of fetal distress, which can occur if the uterus becomes too relaxed and compromises placental blood flow or if there are side effects affecting the mother's cardiovascular status. Therefore, continuous monitoring of FHR is crucial to ensure the fetus is not experiencing distress.
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