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?

Choice A rationale

In the immediate postpartum period, it is normal to observe lochia rubra, which is a dark red discharge, and the passage of small blood clots. A firm, midline fundus at the umbilicus indicates that the uterus is contracting effectively to control bleeding. Given these expected findings within the first hour postpartum, continued monitoring is the appropriate initial action.

Choice B rationale

Notifying the provider is usually indicated when there are deviations from the expected postpartum findings, such as excessive bleeding, a boggy uterus, or signs of infection. The current assessment does not indicate such complications.

Choice C rationale

Encouraging the client to empty her bladder is important in the postpartum period as a full bladder can interfere with uterine contraction and lead to increased bleeding. However, with a firm, midline fundus and expected lochia, this is not the priority action over continued monitoring.

Choice D rationale

Increasing the frequency of fundal massage is indicated when the uterus is boggy or not contracting effectively, leading to increased bleeding. The client's fundus is already firm, so increasing massage is not the immediate priority.

Choice A rationale

When the fetal heart tones are heard loudest in the upper right abdominal quadrant above the umbilicus, it suggests that the fetal back, which transmits sound most clearly, is located in that area. In a breech presentation, the fetal buttocks or feet are in the lower uterine segment, and the head is in the upper portion of the uterus. Therefore, the fetal heart sounds would be best auscultated in the upper abdomen.

Choice B rationale

In the left occiput anterior (LOA) position, the fetal occiput is in the left anterior quadrant of the maternal pelvis. The fetal heart tones are typically heard loudest in the lower left quadrant of the maternal abdomen because the fetal back is usually anterior and slightly to the left.

Choice C rationale

Polyhydramnios is an excessive amount of amniotic fluid. While it can sometimes make it more difficult to auscultate fetal heart tones clearly due to increased fluid volume, it does not directly correlate with the location where the heart tones are heard loudest. The position of the fetus is the primary determinant of the auscultation location.

Choice D rationale

In the right occiput posterior (ROP) position, the fetal occiput is in the right posterior quadrant of the maternal pelvis. The fetal heart tones would typically be heard loudest in the lower right quadrant of the maternal abdomen, as the fetal back would be positioned posteriorly and to the right.