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: The cervix is eﬀaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical eﬀacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.

Choice B reason: The cervix is dilated 3 cm, it is eﬀaced 30%, and the presenting part is 1 cm above the ischial spines is correct, as this follows the correct order and measurement of cervical assessment. Cervical dilation, eﬀacement, and station are recorded in that order to describe the progress of labor. Station refers to the relationship between the presenting part of the fetus and the maternal pelvis, measured by the level of the ischial spines. A negative station means that the presenting part is above the spines, while a positive station means that it is below.

Choice C reason: The cervix is eﬀaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not follow the correct order and measurement of cervical assessment. Cervical eﬀacement is measured in percentage, not in centimeters, and it indicates the thinning or shortening of the cervix. Cervical dilation is measured in centimeters, not in percentage, and it indicates the opening or widening of the cervix.

Choice D reason: The cervix is dilated 3 cm, it is eﬀaced 30%, and the presenting part is 1 cm below the ischial spines is incorrect, as this does not match the documentation of station. A negative station means that the presenting part is above the spines, while a positive station means that it is below.

A. In 3 to 5 days after delivery B. In 6 to 8 days after delivery C. Within 2 days after delivery D. In about 10 days after delivery

Correct Answer is A

Explanation

Choice A reason: In 3 to 5 days after delivery is correct, as this is the average time for breast milk production to begin after birth. Breast milk production is stimulated by the drop in progesterone levels that occurs after the placenta is delivered, as well as by the suckling of the baby. The nurse should encourage the client to breastfeed frequently and eﬀectively to promote milk production and prevent engorgement.

Choice B reason: In 6 to 8 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.

Choice C reason: Within 2 days after delivery is incorrect, as this is a shorter than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should educate the client that before breast milk comes in, the breasts produce colostrum, which is a thick, yellowish ﬂuid that contains antibodies and nutrients for the baby.

Choice D reason: In about 10 days after delivery is incorrect, as this is a longer than average time for breast milk production to begin after birth. Breast milk production usually begins within the first week after birth, although it may vary depending on individual factors. The nurse should assess the client for any factors that may delay or inhibit milk production, such as stress, fatigue, pain, or medication.

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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 in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

Correct Answer is B

Explanation

A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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