A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Document the findings and continue to monitor the client.

Increase the frequency of fundal massage.

Encourage the client to empty her bladder.

Notify the client's provider.

Answer and Explanation

The Correct Answer is A

A.   The findings described are within the expected range for 1 hour postpartum, as lochia rubra and small clots are normal during the early postpartum period. The firm, midline fundus suggests adequate uterine contraction. Documenting the findings and continuing to monitor the client's progress are appropriate.
B.   Increasing the frequency of fundal massage is not necessary as the fundus is already firm and midline.
C.   Encouraging the client to empty her bladder is important for uterine involution, but it is not the priority in this scenario, as the fundus is already firm and midline.
D.   Notifying the client's provider is not necessary at this time, as the findings are within the expected range for the early postpartum period and do not indicate any immediate complications.

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Correct Answer is ["B","D","E"]

Explanation

A. Supplementing with formula after breastfeeding due to perceived weight loss may indicate a misunderstanding of normal newborn feeding patterns and could potentially interfere with establishing a sufficient milk supply. Breastfeeding on demand and ensuring proper latch and
positioning are essential for successful breastfeeding. This statement suggests a need for further education about newborn feeding and breastfeeding management.
B. Breastfeeding frequency is crucial for establishing and maintaining milk supply. Newborns typically need to breastfeed at least 8 to 12 times per day to ensure they receive enough milk and to stimulate milk production in the mother's breasts. This statement indicates that the client
understands the importance of frequent feeding for successful breastfeeding.

C. While covering sore nipples with breast pads can provide comfort and protect clothing from leakage, using plastic-lined breast pads after every feeding may not be necessary and could
potentially worsen nipple discomfort. Plastic-lined breast pads can trap moisture, which may
contribute to nipple soreness or increase the risk of developing nipple thrush. Education may be needed to clarify appropriate nipple care and management of nipple discomfort during
breastfeeding.

D. Meconium stools, which are dark and sticky, are normal for newborns in the first few days of life. As the baby begins to digest breast milk, their stools transition from meconium to a yellow, seedy consistency. This statement indicates that the client understands what to expect regarding the color and consistency of their baby's stools after transitioning to breastfeeding.
E. This statement demonstrates an understanding of breast engorgement, a common occurrence when milk production increases in the breasts. Breasts may become harder, warmer, and more
tender when milk "comes in" or when lactation is established. Recognizing these signs indicates that the client is aware of normal changes in their body related to breastfeeding.

A. "Your baby should sleep at least 6 hours between feedings." B. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." C. "Your baby should wet 6 to 8 diapers per day." D. "Your baby should burp after each feeding."

Correct Answer is C

Explanation

A. Sleeping for long stretches between feedings may indicate inadequate feeding rather than sufficient breast milk intake.
B. Having a wake cycle of 30 to 60 minutes after each feeding is not a reliable indicator of sufficient breast milk intake.
C. Wetting 6 to 8 diapers per day indicates that the baby is adequately hydrated and receiving enough breast milk.

D. Burping after each feeding is important for gas relief but does not directly indicate sufficient breast milk intake.

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A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

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Explanation

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Correct Answer is C

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