A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

Wear a nipple shield.

Express milk from both breasts.

Obtain a prescription for an antibiotic.

Apply a heating pad to her breasts.

Answer and Explanation

The Correct Answer is B

Choice A reason: Wear a nipple shield is incorrect, as this recommendation is not indicated for a client who has engorged breasts. A nipple shield is a thin, ﬂexible device that covers the nipple and areola and can help with latch problems, ﬂat or inverted nipples, or sore nipples. However, a nipple shield can also reduce milk transfer, stimulate less milk production, and cause nipple confusion or preference.

Choice B reason: Express milk from both breasts is correct, as this recommendation can help relieve engorgement and maintain milk production. Engorgement is a normal and expected phenomenon that occurs when the milk comes in, usually around 72 to 96 hr after birth. Engorgement can cause breast fullness, tenderness, warmth, and hardness. The nurse should advise the client to express milk from both breasts by breastfeeding frequently and eﬀectively or by using a breast pump or hand expression.

Choice C reason: Obtain a prescription for an antibiotic is incorrect, as this recommendation is not indicated for a client who has engorged breasts. An antibiotic is used to treat mastitis, which is an infection and inﬂammation of the breast tissue that can cause redness, pain, swelling, warmth, and fever in the aﬀected breast. The nurse should assess the client for signs of mastitis and report any abnormal findings to the provider.

Choice D reason: Apply a heating pad to her breasts is incorrect, as this recommendation can worsen engorgement and cause discomfort. A heating pad can increase blood ﬂow and swelling in the breasts, which can impair milk ﬂow and increase pain. The nurse should advise the client to apply cold compresses or cabbage leaves to her breasts to reduce inﬂammation and discomfort.

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Correct Answer is A

Explanation

Choice A reason: Fundal consistency is correct, as this finding can indicate the eﬀectiveness of oxytocin in stimulating uterine contraction and preventing postpartum hemorrhage. Oxytocin is a uterotonic agent that can enhance or augment uterine contractility and involution. The nurse should monitor the fundal height, consistency, and position and report any signs of uterine atony or excessive bleeding.

Choice B reason: Fetal heart rate is incorrect, as this finding is not relevant for a client who has already delivered the baby. Fetal heart rate can indicate the fetal well-being and response to labor, but it is not aﬀected by oxytocin administration after birth. The nurse should monitor the newborn's vital signs and appearance and report any signs of distress or infection.

Choice C reason: Pulse rate is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Pulse rate can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, fever, or dehydration. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of shock or infection.

Choice D reason: Urinary output is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Urinary output can indicate the client's renal function and ﬂuid balance, but it can be inﬂuenced by many other factors, such as ﬂuid intake, bladder distension, or epidural anesthesia. The nurse should monitor the client's intake and output and report any signs of oliguria or retention.

Choice E reason: Blood pressure is incorrect, as this finding is not specific for evaluating the eﬀectiveness of oxytocin. Blood pressure can indicate the client's hemodynamic status and response to blood loss, but it can be inﬂuenced by many other factors, such as pain, anxiety, preeclampsia, or medication. The nurse should monitor the client's vital signs and ﬂuid balance and report any signs of hypotension or hypertension.

A. Moderate swelling of the labia B. Fundus three fingerbreadths above the umbilicus C. Moderate lochia rubra D. Blood pressure 130/84 mm Hg

Correct Answer is B

Explanation

Choice B reason:
A fundus that is elevated and displaced from the midline indicates a full bladder, which can interfere with uterine contraction and increase the risk of hemorrhage. The nurse should assist the client to void or catheterize her if necessary.

Choice A reason:
Moderate swelling of the labia is a normal finding after vaginal delivery, and does not indicate a need to urinate. The nurse should apply ice packs and perineal pads to reduce edema and discomfort.

Choice C reason:
Moderate lochia rubra is a normal finding during the first 24 hr postpartum, and does not indicate a need to urinate. The nurse should monitor the amount and color of lochia, and change the perineal pads as needed.

Choice D reason:
A blood pressure of 130/84 mm Hg is within the normal range for a postpartum client, and does not indicate a need to urinate. The nurse should monitor the blood pressure for signs of hypertension or hypotension, which can indicate complications such as preeclampsia or hemorrhage.

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A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate eﬀectiveness of this medication?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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