A client is in labor and actively pushing.
The nurse observes decelerations in the fetal heart rate and the fetal head is at the vaginal station.



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?

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:

During the taking-in phase, which typically lasts 2-3 days postpartum, the client's primary focus is on herself and her own

needs. She may be physically exhausted and emotionally overwhelmed by the birthing experience.

Interest in learning about newborn care is more characteristic of the taking-hold phase, which begins around the third day

postpartum.

Choice B rationale:

Concerns about managing at home are more likely to arise during the letting-go phase, which begins around the fourth week

postpartum.

During this phase, the mother is adjusting to her new role and responsibilities, and she may feel anxious about her ability to

care for her baby on her own.

Choice C rationale:

While some mothers may be eager to share their birth stories during the taking-in phase, it is not a universal characteristic of

this phase.

Many mothers are still processing their experiences and may not be ready to talk about them in detail.

Choice D rationale:

The focus on personal needs and recovery is a hallmark of the taking-in phase.

The mother is typically preoccupied with physical comfort, rest, and nourishment.

She may also be emotionally labile, experiencing a range of emotions from euphoria to sadness.