A nurse is assisting in the care of a client who is at 38 weeks of gestation.
What condition is the client most likely experiencing, what are 2 actions the nurse should take to address that
condition, and what are 2 parameters the nurse should monitor to assess the client’s progress?

Rationale for Choice A:

Nipple shields are typically recommended for breastfeeding mothers experiencing nipple pain or thrush. While the client may

be experiencing some breast engorgement due to the hard and warm feeling, there is no indication of nipple pain or thrush.

Therefore, using a nipple shield is not the most appropriate recommendation in this case.

Rationale for Choice B:

Obtaining a prescription for an antibiotic is not warranted at this time. While mastitis, a breast infection, can occur

postpartum, the client's symptoms of moderate lochia rubra and firm, warm breasts are not specific enough to indicate

mastitis. Additionally, unnecessary antibiotic use should be avoided as it can contribute to antibiotic resistance.

Rationale for Choice C:

Applying a heating pad to the breasts may initially provide some comfort, but it can worsen engorgement and inflammation.

Heat stimulates milk production, which can further contribute to the client's discomfort. Applying cold compresses or ice

packs would be a more appropriate intervention for reducing inflammation and breast engorgement.

Rationale for Choice D:

Expressing milk from both breasts is the most appropriate recommendation for the client experiencing breast engorgement.

Regular milk removal helps to reduce milk build-up, alleviate engorgement, and decrease the risk of mastitis. The nurse can

teach the client proper handwashing techniques and breast massage strategies to facilitate effective milk expression.

Additionally, the nurse can encourage the client to breastfeed frequently, as this is the most efficient way to remove milk and

prevent engorgement.

Additional Notes:

The client's postpartum day (3 days) is a significant factor in considering the cause of her symptoms. Breast engorgement is

common during the first few days postpartum as milk production becomes established.

The nurse should assess the client's breastfeeding technique and ensure proper latching to prevent nipple trauma and

encourage effective milk removal.

Monitoring the client's temperature and other vital signs is crucial for identifying potential signs of infection, such as mastitis.

Providing the client with supportive measures such as comfortable bras and pain relief medications can also contribute to her

comfort and well-being.

By addressing the underlying cause of breast engorgement (milk build-up) through milk expression, the nurse can effectively

manage the client's symptoms and prevent potential complications like mastitis.

Rationale for Choice A: Increase IV fluid rate

While hypotension is a potential complication of epidural anesthesia, increasing the IV fluid rate is not the first-line

intervention in this scenario. While fluid resuscitation may be necessary in some cases, it has the potential to further decrease

the client's blood pressure and exacerbate the situation. Additionally, the cause of the hypotension is not yet fully determined,

and increasing fluids without addressing the underlying cause could mask or worsen the problem.

Rationale for Choice B: Place the client in a lateral position

Supine hypotension, a sudden drop in blood pressure upon assuming a supine position, is a common complication of epidural

anesthesia. This occurs due to aortocaval compression, where the enlarged uterus compresses the major blood vessels

supplying the lower body and returning blood to the heart. Placing the client in a lateral position, preferably tilted slightly to

the left, alleviates this compression, allowing blood to flow more freely and improving blood pressure. This intervention is

simple, non-invasive, and has the potential to quickly resolve the hypotension without further interventions.

Rationale for Choice C: Notify the provider

While notifying the provider is certainly warranted in this situation, it should not be the first action taken. The client's vital

signs indicate a potentially serious situation requiring immediate intervention. Delaying action while waiting for the provider

could have negative consequences for both the client and the fetus. Therefore, placing the client in a lateral position should be

the immediate priority followed by notifying the provider to discuss further management.

Rationale for Choice D: Elevate the legs

Elevating the legs is a standard intervention for managing orthostatic hypotension, which is characterized by dizziness or

lightheadedness upon standing. However, in this case, the client is already supine and experiencing supine hypotension, not

orthostatic hypotension. Elevating the legs would not address the aortocaval compression and may even worsen the venous

return, further decreasing blood pressure.

Additional Notes:

Other interventions that may be considered depending on the client's response and provider's assessment include

administering vasopressors to increase blood pressure and administering oxygen to improve fetal oxygenation.

Continuous monitoring of the client's vital signs and fetal heart rate is crucial to assess the effectiveness of interventions and

identify any further deterioration.

Prompt communication with the provider is essential to ensure timely and appropriate management of the situation.