A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
The client is exhibiting early indications of mastitis.
Additional interventions are not indicated at this time.
The client should be advised to remove her nursing bra.
Application of a heating pad to the breasts is indicated.
The Correct Answer is B
Choice a reason:
Mastitis is an infection of the breast tissue that results in pain, swelling, warmth, and redness. The symptoms of mastitis typically include breast tenderness, redness on the skin, breast pain, and sometimes fever and malaise. While the client's breasts are described as hard and warm, which could be associated with mastitis, the absence of other key symptoms such as fever or flu-like symptoms suggests that mastitis may not be the issue here.
Choice b reason:
Three days postpartum, it is normal for the fundus to be below the umbilicus and for lochia rubra to be present. The hardness and warmth of the breasts could be due to milk coming in, which is also a normal postpartum change. Without additional symptoms of concern, such as fever, severe pain, or signs of infection, it is reasonable to conclude that no additional interventions are required at this time.
Choice c reason:
Removing a nursing bra can provide comfort, especially if it is too tight and contributing to breast engorgement or clogged ducts. However, there is no indication that the client's nursing bra is causing an issue. Nursing bras are designed to support the breasts during breastfeeding and typically do not need to be removed unless they are causing specific problems.
Choice d reason:
Applying a heating pad can help with milk let-down and relieve discomfort from engorgement or clogged ducts. However, since the client is not exhibiting signs of mastitis or severe engorgement, and the warmth of the breasts may be due to normal postpartum changes, the application of a heating pad is not necessarily indicated at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0504"]
Explanation
To calculate the estimated date of birth (EDB), also known as the due date, we use Naegele's Rule, which involves adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). Using this rule, if the LMP was on July 27, the EDB would be:
- Add one year: July 27, 2024
- Subtract three months: April 27, 2024
- Add seven days: May 4, 2024
Therefore, the EDB in MMDD format is 0504.
Reason:
Naegele's Rule is a standard way of calculating the due date for a pregnancy. The rule estimates the expected date of delivery (EDD) by adding one year, subtracting three months, and adding seven days to the date of a woman's last menstrual period (LMP). This calculation assumes a regular menstrual cycle of 28 days and ovulation occurring on the 14th day of the cycle. The EDB is typically set at 40 weeks from the LMP, which is approximately 280 days. While this method provides an estimate, only about 4% of births occur on the exact due date, and most births occur within a range of two weeks before or after the estimated due date.
It's important to note that the EDB is an estimate and can be influenced by factors such as the length of menstrual cycles, the exact day of ovulation, and the date of conception. Ultrasounds and other prenatal tests can provide additional information to refine the due date estimate as the pregnancy progresses.
Correct Answer is B
Explanation
Choice A reason:
The absence of vitamin K in newborns is a concern as it is essential for blood clotting. Newborns are at risk of vitamin K deficiency bleeding (VKDB), which can lead to serious bleeding issues but not typically jaundice. VKDB is preventable with a vitamin K injection at birth.
Choice B reason:
Physiologic jaundice is common in newborns and usually appears between the second and fourth day after birth. It occurs due to the baby's liver not being mature enough to get rid of bilirubin in the bloodstream. This type of jaundice is generally harmless and resolves on its own within two weeks.
Choice C reason:
Maternal cocaine abuse can have numerous adverse effects on a newborn, including premature birth and withdrawal symptoms, but it does not directly cause jaundice. The symptoms of cocaine exposure in newborns can include tremors, muscle spasms, and difficulty feeding.
Choice D reason:
Blood group incompatibility, such as Rh disease or ABO incompatibility, can lead to hemolytic disease of the newborn (HDN), which can cause jaundice. This occurs when the mother's antibodies attack the baby's red blood cells, leading to increased bilirubin levels.
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