A breastfeeding woman develops engorged breasts at 3 days postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman:
Breastfeeds her infant every 2 hours
Avoids using a breast pump
Skips feedings to let her sore breasts rest
Reduces her fluid intake for 24 hours
The Correct Answer is A
A) Wash your hands before and after you use the bathroom and change your sanitary pad:
The most important instruction for preventing postpartum infection is proper hand hygiene. The risk of infection in the postpartum period is high, especially because the perineum and cervix are healing after delivery. By washing hands before and after using the bathroom or changing sanitary pads, the mother reduces the risk of introducing harmful bacteria into the vaginal area. Proper hand hygiene helps minimize the risk of urinary tract infections (UTIs), wound infections, and endometritis, which are all common postpartum complications.
B) Do not take tub baths for eight weeks:
While it is true that taking tub baths can potentially introduce bacteria into the vaginal area, particularly if the perineum is healing from a tear or episiotomy, this is a secondary concern. The priority is hand hygiene, which directly prevents infection by limiting bacterial exposure. The recommendation to avoid tub baths is generally valid for the first 6 weeks, but it is less critical than hand washing.
C) Use tampons instead of pads as they are better at inhibiting bacterial growth:
Using tampons is not recommended in the postpartum period because they can increase the risk of toxic shock syndrome and can irritate the vaginal area or interfere with uterine healing. Pads are preferred to absorb lochia (postpartum discharge) and are safer for vaginal healing. Tampons do not inhibit bacterial growth more effectively than pads, and the use of tampons can actually increase the risk of infection, so this option is incorrect.
D) Douche with a mild antiseptic twice a day for two weeks, starting at day three:
Douching is not recommended during the postpartum period. It can disrupt the natural vaginal flora, increase the risk of infections like vaginitis, and delay the healing process. The vagina has its own natural defense mechanisms, and douching with antiseptics is unnecessary and can do more harm than good. Instead, the focus should be on keeping the area clean and dry and practicing proper hand hygiene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Massage the fundus:
The first priority in this situation is to massage the fundus to help control potential postpartum hemorrhage caused by uterine atony. A boggy fundus (soft and not firm) suggests that the uterus is not contracting effectively, which can lead to excessive bleeding. Massaging the fundus stimulates uterine contractions, which can help reduce bleeding by compressing the blood vessels that were supplying the placenta. The nurse should begin with this intervention immediately to address the most likely cause of the bleeding.
B) Take the patient's blood pressure:
While vital signs such as blood pressure are important for assessing shock or ongoing hemorrhage, massaging the fundus takes priority in this scenario to directly address the cause of the bleeding. Taking the blood pressure is not the most immediate intervention for this specific situation because the primary issue here is uterine atony, not hemodynamic instability (although it will need to be assessed shortly thereafter).
C) Start an IV:
Starting an IV may be important if there is significant blood loss, but it is not the first priority in this scenario. The nurse should first focus on stabilizing the uterus by massaging the fundus. IV access will become more critical if the bleeding is not controlled after the fundus is massaged and other interventions are required.
D) Have the patient empty her bladder:
While a full bladder can sometimes displace the uterus and cause it to be less effective at contracting, this is a secondary concern. The first priority is to address the uterine atony by massaging the fundus. Once the fundus is firm and bleeding is under control, the nurse can then consider having the patient empty her bladder to ensure it isn't interfering with the uterus' ability to contract.
Correct Answer is A
Explanation
A) Mother Rh-, baby Rh+:
RhoGAM (Rh immune globulin) is administered to a mother who is Rh-negative and has delivered a baby who is Rh-positive. If the Rh-negative mother is exposed to Rh-positive blood (via the baby’s blood during delivery), her immune system may start producing antibodies against Rh-positive cells, which could affect future pregnancies. The RhoGAM injection works by preventing the mother from developing these antibodies, thereby protecting any subsequent pregnancies from hemolytic disease of the newborn (HDN) in which the mother’s antibodies attack the baby’s red blood cells. This is a crucial preventive measure to avoid sensitization to Rh-positive blood.
B) Mother Rh-, baby Rh-:
If both the mother and baby are Rh-negative, there is no concern about the development of antibodies because there is no exposure to Rh-positive blood. Therefore, RhoGAM is not necessary in this situation.
C) Mother Rh+, baby Rh+:
In this scenario, the mother is Rh-positive, so she cannot develop antibodies against Rh-positive blood, regardless of the baby's Rh status. Hence, RhoGAM is not required because there is no risk of Rh incompatibility.
D) Mother Rh+, baby Rh-:
Since the mother is Rh-positive, there is no risk of her immune system attacking an Rh-negative baby’s red blood cells. Thus, RhoGAM is not needed in this case either.
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