A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?
Additional interventions not indicated at this time.
Application of a heating pad to the breasts is indicated.
The client should be advised to remove her nursing bra.
The client is exhibiting early indications of mastitis.
The Correct Answer is A
Choice A Reason:
The findings described are typical for a client who is 3 days postpartum. The fundus being three fingerbreadths below the umbilicus, moderate lochia rubra, and full, warm breasts are all normal postpartum changes. The fundus should gradually descend into the pelvis, and lochia rubra is expected during the first few days postpartum. Breast fullness and warmth indicate the onset of milk production, which is normal and does not require additional interventions.
Choice B Reason:
Applying a heating pad to the breasts is not indicated in this scenario. While heat can sometimes be used to relieve engorgement, it is not necessary unless the client is experiencing significant discomfort or other symptoms that suggest a need for intervention. The described findings do not indicate such a need.
Choice C Reason:
Advising the client to remove her nursing bra is not appropriate. Wearing a well-fitting nursing bra can provide support and comfort, especially as the breasts become fuller with milk production. There is no indication from the findings that the client should remove her nursing bra
Choice D Reason:
The client is not exhibiting early indications of mastitis. Mastitis typically presents with symptoms such as localized breast pain, redness, fever, and flu-like symptoms. The described findings of full and warm breasts are normal for the postpartum period and do not suggest an infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The priority action is to assess the safety of both the client and the newborn. Asking the client if she has considered harming her newborn is crucial to determine if there is an immediate risk of harm. This question helps identify any potential danger and allows for immediate intervention if necessary. Ensuring the safety of the mother and baby is the top priority in managing postpartum depression.
Choice B Reason:
Anticipating a prescription for an antidepressant is important, but it is not the immediate priority. Medication can be part of the treatment plan for postpartum depression, but first, it is essential to assess the client’s safety and risk of harm to herself or her newborn.
Choice C Reason:
Reinforcing postpartum and newborn care discharge teaching is beneficial for the client’s overall understanding and management of her condition. However, it does not address the immediate concern of potential harm to the newborn or the severity of the client’s depressive symptoms
Choice D Reason:
Assisting the family to identify proper use of positive coping skills is a valuable long-term strategy for managing postpartum depression. However, the immediate priority is to assess the client’s safety and ensure there is no risk of harm to herself or her newborn.
Correct Answer is C
Explanation
Choice A Reason:
It is not typical to see products of conception in vaginal bleeding after a D&C, as the procedure is intended to remove all remaining tissue from the uterus. Post-procedure bleeding should be monitored, but the presence of products of conception would indicate an incomplete procedure.
Choice B Reason:
While a balanced diet is important for recovery, there is no specific recommendation to increase the intake of zinc-rich foods following a D&C. The focus should be on overall nutritional support rather than specific nutrients.
Choice C Reason:
Vaginal intercourse can generally be resumed after 2 weeks, provided there are no complications and the client feels comfortable. This allows time for the cervix to close and reduces the risk of infection.
Choice D Reason:
Aspirin is not recommended for pain relief after a D&C because it can increase the risk of bleeding. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are typically recommended instead.
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