A nurse is caring for a client who is 12 hours postpartum.
The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment.
Which of the following is an expected finding during this period?

Rationale for Choice A:

Nipple shields are typically recommended for breastfeeding mothers experiencing nipple pain or thrush. While the client may

be experiencing some breast engorgement due to the hard and warm feeling, there is no indication of nipple pain or thrush.

Therefore, using a nipple shield is not the most appropriate recommendation in this case.

Rationale for Choice B:

Obtaining a prescription for an antibiotic is not warranted at this time. While mastitis, a breast infection, can occur

postpartum, the client's symptoms of moderate lochia rubra and firm, warm breasts are not specific enough to indicate

mastitis. Additionally, unnecessary antibiotic use should be avoided as it can contribute to antibiotic resistance.

Rationale for Choice C:

Applying a heating pad to the breasts may initially provide some comfort, but it can worsen engorgement and inflammation.

Heat stimulates milk production, which can further contribute to the client's discomfort. Applying cold compresses or ice

packs would be a more appropriate intervention for reducing inflammation and breast engorgement.

Rationale for Choice D:

Expressing milk from both breasts is the most appropriate recommendation for the client experiencing breast engorgement.

Regular milk removal helps to reduce milk build-up, alleviate engorgement, and decrease the risk of mastitis. The nurse can

teach the client proper handwashing techniques and breast massage strategies to facilitate effective milk expression.

Additionally, the nurse can encourage the client to breastfeed frequently, as this is the most efficient way to remove milk and

prevent engorgement.

Additional Notes:

The client's postpartum day (3 days) is a significant factor in considering the cause of her symptoms. Breast engorgement is

common during the first few days postpartum as milk production becomes established.

The nurse should assess the client's breastfeeding technique and ensure proper latching to prevent nipple trauma and

encourage effective milk removal.

Monitoring the client's temperature and other vital signs is crucial for identifying potential signs of infection, such as mastitis.

Providing the client with supportive measures such as comfortable bras and pain relief medications can also contribute to her

comfort and well-being.

By addressing the underlying cause of breast engorgement (milk build-up) through milk expression, the nurse can effectively

manage the client's symptoms and prevent potential complications like mastitis.

Choice A rationale:

There is no evidence to suggest that epidural anesthesia delays the rupture of fetal membranes. The timing of rupture of fetal

membranes is influenced by various factors, including the strength of uterine contractions, the position of the baby, and the

elasticity of the amniotic sac. Epidural anesthesia does not directly affect these factors.

Choice B rationale:

Epidural anesthesia can prolong labor by interfering with the natural process of labor. It can weaken uterine contractions,

slow down cervical dilation, and potentially lead to a prolonged second stage of labor. This is because the anesthesia blocks the

nerve signals that control the muscles of the uterus. When these signals are blocked, the contractions may become less

frequent and less intense. This can delay the progress of labor and increase the risk of interventions such as forceps delivery

or cesarean section.

Choice C rationale:

While epidural anesthesia can have some effects on the baby, it is not a primary cause of fetal depression. Fetal depression is

typically caused by other factors, such as decreased oxygen supply to the baby, maternal infection, or placental problems.

Epidural anesthesia can sometimes lead to a temporary decrease in the baby's heart rate, but this is usually well-managed by

the healthcare team and does not typically lead to significant fetal depression.

Choice D rationale:

Epidural anesthesia does not typically cause maternal hypertension. In fact, it can sometimes have the opposite effect and

cause a slight decrease in blood pressure. This is because the anesthesia can relax the blood vessels, which can lead to a drop

in blood pressure. However, this is usually not a significant concern and is easily managed by the healthcare team.