A woman gave birth 48 hours ago to a healthy infant girl.
She has decided to bottle feed.
During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.
Which guidance should the nurse provide to the client at this time?

Express small amounts of milk from the breasts to relieve the pressure.

Wearing a loose-fitting bra to prevent nipple irritation.

Apply cold packs to the breasts for comfort.

Run warm water on her breasts during a shower.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Expressing milk when bottle-feeding can stimulate further milk production, which would exacerbate the engorgement and discomfort. The goal is to discourage milk production.

Choice B rationale

While a supportive bra is generally recommended for comfort, a loose-fitting bra might not provide adequate support to reduce swelling and discomfort associated with engorgement. A firm, supportive bra is usually advised.

Choice C rationale

Cold packs cause vasoconstriction, which helps to reduce blood flow to the breasts, thereby decreasing swelling, inflammation, and pain associated with engorgement. This provides symptomatic relief without stimulating milk production.

Choice D rationale

Warm water can stimulate milk flow, which is counterproductive when trying to suppress lactation in a bottle-feeding mother experiencing engorgement. Warmth increases blood flow and can worsen swelling and discomfort.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

White blood cell count: Expected—mild leukocytosis is normal postpartum due to physiological stress.
Blood clot size: Expected—small clots, like a pea-sized clot, are common and not concerning unless excessive bleeding occurs.
Uterine findings: Expected—firm and midline uterus indicating effective involution.
Lochia findings: Expected—progressing normally without signs of infection (no foul odor).
Calf findings: Expected—a single varicose vein without tenderness or swelling is not concerning.
Blood pressure: Expected—within normal postpartum range.

A. Spontaneous rupture of membranes. B. Fetal head compression. C. Umbilical cord compression. D. Utero-placental insufficiency.

Correct Answer is B

Explanation

Choice A rationale

Spontaneous rupture of membranes (SROM) can sometimes be associated with variable decelerations due to potential cord compression if the presenting part is not well applied, but it is not the most likely cause of early decelerations. Early decelerations reflect a physiological response to fetal head compression.

Choice B rationale

Fetal head compression during a contraction leads to vagal nerve stimulation, causing a transient decrease in the fetal heart rate. This deceleration is typically gradual in onset and recovery, mirroring the contraction pattern, and is considered a benign finding.

Choice C rationale

Umbilical cord compression typically results in variable decelerations, which are abrupt decreases in FHR that are not necessarily associated with uterine contractions. The shape and timing of variable decelerations differ significantly from the gradual, consistent pattern of early decelerations.

Choice D rationale

Utero-placental insufficiency usually manifests as late decelerations, which are gradual decreases in FHR that begin after the peak of the contraction and recover after the contraction ends. This pattern indicates fetal hypoxia and is a concerning finding, distinct from early decelerations.

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A woman gave birth 48 hours ago to a healthy infant girl.She has decided to bottle feed.During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.Which guidance should the nurse provide to the client at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 32-year-old female client who is 2 days postpartum in the postpartum unit. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern?

Correct Answer is B

Explanation

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A woman gave birth 48 hours ago to a healthy infant girl.She has decided to bottle feed.During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.Which guidance should the nurse provide to the client at this time?

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A woman gave birth 48 hours ago to a healthy infant girl.
She has decided to bottle feed.
During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation.
Which guidance should the nurse provide to the client at this time?