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. Fetal head compression B. Polyhydramnios C. Maternal fever D. Umbilical cord compression

Correct Answer is D

Explanation

Choice A reason:
Fetal head compression is incorrect, as this factor can cause early decelerations in the fetal heart rate. Early decelerations are symmetrical decreases in the FHR that mirror the contractions, which indicate fetal head compression and vagal stimulation. Fetal head compression occurs as the fetus descends into the birth canal and does not pose a threat to the fetal well-being.

Choice B reason:
Polyhydramnios is incorrect, as this factor can cause variable or late decelerations in the fetal heart rate, depending on the underlying cause. Polyhydramnios refers to an excessive amount of amniotic ﬂuid, which can result from fetal anomalies, maternal diabetes, multiple gestation, or other conditions. Polyhydramnios can cause umbilical cord prolapse, uterine overdistension, or placental abruption, leading to reduced blood ﬂow and oxygen delivery to the fetus.

Choice C reason:
Maternal fever is incorrect, as this factor can cause late decelerations in the fetal heart rate. Late decelerations are symmetrical decreases in the FHR that begin after the peak of the contraction and return to baseline after the contraction ends, which indicate uteroplacental insufficiency. Maternal fever can increase maternal and fetal metabolism and oxygen demand, leading to fetal hypoxia and acidosis.

Choice D reason:
Umbilical cord compression is correct, as this factor can cause variable decelerations in the fetal heart rate. Variable decelerations are abrupt decreases in the FHR that vary in onset, duration, and depth, which indicate umbilical cord compression and reduced blood ﬂow to the fetus. Umbilical cord compression can occur due to cord prolapse, nuchal cord, short cord, or other causes. The nurse should reposition the client, administer oxygen, and prepare for delivery if indicated.

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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

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

Correct Answer is D

Explanation

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