A nurse is caring for a postpartum client who is breastfeeding their newborn and reports that their nipples have become sore and cracked.
Which of the following statements should the nurse make?

Choice A rationale

A perineal hematoma is a collection of blood in the connective tissue beneath the skin, often caused by trauma during childbirth. The reported findings of increasing perineal pain, pressure, purplish discoloration, and swelling are classic signs. The purplish hue indicates extravasated blood, and the swelling reflects the accumulation of fluid, which can exert significant pressure on surrounding tissues, leading to severe discomfort and a palpable mass.

Choice B rationale

Retained placental fragments typically manifest as persistent or excessive postpartum bleeding, often bright red, and can lead to uterine subinvolution and infection. While pain might be present due to uterine contractions, it would not typically present as a localized, purplish, swollen area on the perineum. This finding is not consistent with the pathophysiology of retained placental fragments, which primarily affects the uterus.

Choice C rationale

A laceration is a tear in the soft tissues of the perineum or vagina, resulting in bright red bleeding, pain, and sometimes a visible opening. While pain is present, a laceration would not typically present with a 4 cm purplish discoloration and significant swelling without active, bright red bleeding from the tear site itself. The described findings are more indicative of internal bleeding and tissue accumulation rather than an open wound.

Choice D rationale

Ecchymosis is a bruise, characterized by superficial extravasation of blood into the skin or mucous membranes, resulting in a purplish discoloration. While the purplish discoloration is consistent, ecchymosis alone typically does not involve the significant palpable swelling and increasing pressure described. The extent of swelling and pressure points to a deeper collection of blood, distinguishing it from simple superficial bruising.

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy for hyperbilirubinemia. Glucose water provides no nutritional benefit, can lead to decreased breast milk intake, and does not aid in the excretion of bilirubin, which is primarily excreted through conjugated bile in stool.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment for hyperbilirubinemia is incorrect. Breastfeeding should be continued and encouraged, as adequate hydration and caloric intake are crucial for promoting bowel movements, which help in the excretion of bilirubin from the body. Interruption of breastfeeding can also negatively impact milk supply.

Choice C rationale

Monitoring intake and output is critical for a newborn undergoing phototherapy. Phototherapy can increase insensible fluid losses through the skin, potentially leading to dehydration. Close monitoring of fluid intake (e.g., breastfeeding, formula) and urine/stool output ensures adequate hydration and helps assess the effectiveness of bilirubin excretion.

Choice D rationale

Applying lotions and ointments throughout phototherapy treatment is contraindicated. These products can absorb the light emitted by the phototherapy unit, leading to potential burns or uneven light distribution on the newborn's skin, thereby reducing the effectiveness of the treatment for hyperbilirubinemia.