A breastfeeding woman develops engorged breasts at 3 days postpartum.
What action would help this woman achieve her goal of reducing the engorgement?
Reduces her fluid intake for 24 hours.
Breastfeeds her infant every 2 hours.
Avoids using a breast pump.
Skips feedings to let her sore breasts rest.
The Correct Answer is B
Choice A rationale
Reducing fluid intake will not alleviate breast engorgement and may even be detrimental to milk production and overall maternal hydration. Engorgement is caused by increased blood flow and milk production in the breasts, not excess fluid intake.
Choice B rationale
Frequent breastfeeding, ideally every 1-2 hours, helps to remove milk from the breasts, which relieves pressure and engorgement. Regular emptying of the breasts signals the body to regulate milk production and prevents the buildup of milk that causes discomfort and can lead to complications like mastitis.
Choice C rationale
Avoiding the use of a breast pump when breasts are engorged can worsen the condition. A breast pump can be used to express milk and relieve pressure if the infant is not feeding effectively or frequently enough. Complete milk removal is key to reducing engorgement.
Choice D rationale
Skipping feedings will exacerbate breast engorgement as milk will continue to accumulate in the breasts, increasing pressure, pain, and the risk of complications. Regular milk removal is essential for managing engorgement and establishing a healthy breastfeeding pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A displaced fundus from the midline, often deviated to the right and boggy, suggests a full bladder interfering with uterine contraction and involution. A distended bladder prevents the uterus from clamping down effectively, increasing the risk of postpartum hemorrhage. Immediate intervention is required to assist the client in emptying her bladder, which should allow the uterus to return to the midline and contract firmly.
Choice B rationale
A fundal height below the umbilicus on the first postpartum day is a normal finding. Following delivery, the uterus begins to descend approximately one fingerbreadth (1 cm) per day. Therefore, a fundus below the umbilicus at 24 hours postpartum indicates normal uterine involution.
Choice C rationale
A decreased urge to void is common in the immediate postpartum period due to factors such as perineal swelling, pain, and the effects of anesthesia. While it's important to monitor urinary output, a decreased urge to void in the first 24 hours is not typically considered a finding requiring immediate intervention unless accompanied by other signs of urinary retention or bladder distension.
Choice D rationale
Increased urine output is also a normal finding in the postpartum period as the body eliminates excess fluid volume accumulated during pregnancy. Diuresis typically begins within 12 to 24 hours after delivery and can last for several days. This is a physiological process and does not require immediate intervention.
Correct Answer is D
Explanation
Choice A rationale
The ventrogluteal muscle, located in the hip, is a safe site for intramuscular injections in adults and children older than seven months due to its distance from major nerves and blood vessels. However, the vastus lateralis muscle in the thigh is the preferred site for IM injections in newborns and infants due to its well-developed muscle mass and accessibility.
Choice B rationale
The deltoid muscle, located in the upper arm, is small and not well-developed in newborns, making it an unsuitable site for intramuscular injections. There is also a risk of injury to the brachial nerve and blood vessels in this area in neonates.
Choice C rationale
The dorsogluteal muscle, located in the buttocks, is no longer the recommended site for intramuscular injections in infants and young children due to the proximity of the sciatic nerve and major blood vessels, increasing the risk of nerve damage.
Choice D rationale
The vastus lateralis muscle, located on the anterolateral aspect of the thigh, is the recommended site for intramuscular injections in newborns. It is a large, well-developed muscle that is easily accessible and away from major nerves and blood vessels, making it a safe and effective site for administering vitamin K to prevent hemorrhagic disease of the newborn.
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