A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider (HCP) in two weeks.
Which action should the practical nurse (PN) take?
Recommend that the client wear a supportive bra to prevent leaking of fluid.
Reschedule the client's prenatal appointment for the following day.
Explain that this is normal, but can be assessed further at the next prenatal visit.
Obtain additional data by asking the client if her areolae have become darker.
The Correct Answer is C
Choice A rationale
While wearing a supportive bra can manage symptoms like leaking, it does not address the underlying physiological changes or provide reassurance about their normalcy during pregnancy. The primary concern is to alleviate anxiety and provide accurate information, not just symptom management. Breast changes are common, and this choice does not prioritize assessment or explanation.
Choice B rationale
Rescheduling the appointment prematurely might cause unnecessary anxiety for the client if the symptoms are indeed normal. It disrupts the established prenatal care schedule without sufficient clinical indication. Unless acute distress or clear signs of pathology are present, waiting for the scheduled visit is generally appropriate.
Choice C rationale
During the third trimester, breast tissue undergoes significant hormonal changes in preparation for lactation, leading to increased vascularity, glandular growth, and sometimes the leakage of colostrum, a yellowish fluid. These are normal physiological adaptations, and reassuring the client while noting it for the upcoming visit provides appropriate, evidence-based care.
Choice D rationale
While darkened areolae are another common physiological change during pregnancy due to increased melanocyte-stimulating hormone, asking about it does not directly address the client's current concerns about "lumpy places" or fluid leakage. It's a related but separate observation, and the initial focus should be on explaining the normal changes the client is reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Uterine muscle tone is the highest priority assessment postpartum, especially after a large infant delivery. A boggy uterus indicates uterine atony, a leading cause of postpartum hemorrhage. The uterus must contract firmly to compress blood vessels and prevent excessive bleeding. Prompt intervention is crucial to prevent hypovolemic shock. Normal uterine tone is firm and midline.
Choice B rationale
Vulvo-perineal tissues and episiotomy assessment is important to identify hematomas or excessive swelling. While significant, these are typically less life-threatening in the immediate postpartum period compared to uterine atony. Hematomas can cause pain and pressure, and wound integrity is vital for infection prevention.
Choice C rationale
Body temperature assessment is important to detect fever, which could indicate infection. Postpartum infection is a concern, but hypovolemic shock from hemorrhage is a more immediate and critical threat to maternal well-being. Normal postpartum temperature is typically below 38°C (100.4°F).
Choice D rationale
Breast engorgement and nipple integrity are important for promoting successful breastfeeding and preventing complications like mastitis. However, these are not immediate life-threatening concerns in the initial hours after delivery. Early assessment focuses on maternal physiological stability.
Correct Answer is D
Explanation
Choice A rationale
Collecting a urine specimen for electrolytes and protein would provide data related to renal function and fluid balance, but it does not directly address the client's current subjective symptoms of restlessness and apprehension. These symptoms are more indicative of potential hypoxemia or a psychological response to stress, which requires a more immediate and direct assessment and intervention focused on maternal-fetal well-being rather than baseline lab work. Normal urine specific gravity is 1.005-1.030, and protein should be negative.
Choice B rationale
Moving the client into a dorsal recumbent position can actually compress the inferior vena cava, leading to supine hypotensive syndrome, which further compromises placental perfusion and exacerbates fetal distress. This position is contraindicated in laboring clients, particularly when signs of potential distress are present. The ideal position for laboring clients is typically left lateral, which optimizes uterine perfusion and oxygenation.
Choice C rationale
Encouraging the client to push with the next contraction is inappropriate given the client's symptoms of restlessness and apprehension, especially at 42 weeks gestation with chorioamnionitis. These symptoms could indicate evolving fetal distress or a change in maternal status requiring further assessment, not active pushing. Pushing without complete cervical dilation can lead to cervical edema or trauma.
Choice D rationale
Providing information about the baby's status can alleviate the client's anxiety and apprehension by addressing her immediate concerns about the well-being of her fetus. Restlessness and apprehension in a laboring client, particularly with a diagnosis of chorioamnionitis, can be a symptom of hypoxemia or other complications. Open communication and reassurance are crucial in managing maternal stress and promoting a sense of control.
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