A nurse is assisting with the care of a client who is in labor and has the urge to push.
Which of the following instructions should the nurse give the client?

Choice A rationale:

Swelling in both breasts is a common finding in breastfeeding women, especially in the early postpartum period. It is often due

to engorgement, which is caused by an oversupply of milk and/or infrequent milk removal.

While engorgement can sometimes lead to mastitis, it is not a definitive sign of the condition.

Other causes of bilateral breast swelling, such as milk stasis or plugged ducts, should also be considered.

Choice B rationale:

Cracked and bleeding nipples can be a symptom of mastitis, but they are not always present.

They can also be caused by other factors, such as improper latch, thrush, or dry skin.

It is important to assess for other signs and symptoms of mastitis, such as fever, chills, and breast tenderness, to make a

definitive diagnosis.

Choice C rationale:

A red and painful area in one breast is a classic sign of mastitis.

This is typically caused by inflammation of the breast tissue, often due to a bacterial infection.

The redness and pain are usually localized to the affected area, and may be accompanied by warmth, swelling, and firmness.

Choice D rationale:

An increase in breast milk production is not a sign of mastitis.

In fact, it is often a sign that breastfeeding is going well.

However, if the milk is not being removed effectively, it can lead to engorgement and blocked ducts, which can increase the

risk of mastitis.

Choice A rationale:

Pushing continuously throughout the entire contraction can lead to maternal exhaustion and may not be the most effective way to progress labor. It’s important for the mother to conserve her energy and work with her body’s natural rhythms.

Choice B rationale:

Taking a deep, cleansing breath before and after each contraction can help the mother manage pain and keep her energy up.

This technique is often recommended because it allows the mother to rest briefly and gather strength for the next contraction.

Choice C rationale:

While it’s important for the nurse to monitor contractions and provide guidance, the urge to push is a natural response that

can vary among individuals. Telling the mother when to push according to contractions may not align with her body’s natural

instincts.

Choice D rationale:

Holding one’s breath and pushing while someone counts to ten is an outdated practice. This method can cause unnecessary

strain and doesn’t take into account the individual rhythms and responses of the mother’s body.