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 B

Explanation

Choice A reason:

A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body eliminates excess ﬂuid accumulated during pregnancy.

Choice B reason:

A temperature of 100.4 F for two days indicates a possible infection, such as endometritis or mastitis, and requires further evaluation and treatment.

Choice C reason:

Chills shortly following delivery are common and benign and are caused by hormonal changes and ﬂuid shifts.

Choice D reason:

A fundus at the umbilicus level is expected for a postpartum client and indicates that the uterus is involuting properly.

A. Precipitous birth B. Small for gestational age newborn C. Two-vessel umbilical cord D. Gestational hypertension

Correct Answer is A

Explanation

Choice A reason: A precipitous birth is a delivery that occurs in less than 3 hours from the onset of labor. This can cause uterine atony, which is the failure of the uterus to contract and compress the blood vessels after the placenta is delivered. Uterine atony is the most common cause of postpartum hemorrhage²³.

Choice B reason: A small for gestational age newborn is not a risk factor for postpartum hemorrhage. It may be associated with other conditions, such as placental insufficiency or intrauterine growth restriction, but these do not directly increase the risk of bleeding after delivery.

Choice C reason: A two-vessel umbilical cord is a cord that has one artery and one vein instead of the normal two arteries and one vein. This can be a marker for congenital anomalies or placental abnormalities, but it does not increase the risk of postpartum hemorrhage by itself.

Choice D reason: Gestational hypertension is a condition where the blood pressure rises above 140/90 mm Hg after 20 weeks of pregnancy. It can lead to complications such as preeclampsia, eclampsia, or HELLP syndrome, which can aﬀect the clotting system and cause bleeding disorders. However, gestational hypertension alone does not increase the risk of postpartum hemorrhage unless it is associated with these severe conditions¹⁴.

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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 collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hours ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Correct Answer is A

Explanation

A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

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