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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. At the level of the umbilicus.
Choice A rationale:
The fundus is typically not found 2 cm above the umbilicus 12 hours postpartum. This position is more common immediately after delivery or in cases of uterine atony or retained placental fragments.
Choice B rationale:
At 12 hours postpartum, the uterine fundus is expected to be at the level of the umbilicus. This indicates normal involution of the uterus, where it contracts and shrinks back to its pre-pregnancy size.
Choice C rationale:
One fingerbreadth above the symphysis pubis is not a typical position for the fundus 12 hours after delivery. This position is more likely several days postpartum as the uterus continues to involute.
Choice D rationale:
The fundus being to the right of the umbilicus may indicate a full bladder, which can push the uterus to one side. This is not a normal finding 12 hours postpartum and would require intervention to empty the bladder.
: https://bchsfoutreach.ucsf.edu/sites/bchsfoutreach.ucsf.edu/files/handouts/Washington%20Hospital%20Postpartum%204-2018.pdf : https://nursekey.com/fundal-palpation-postpartum/
Correct Answer is A
Explanation
Choice A Reason:
Using a cotton-tipped swab to clean a newborn's nares can be dangerous. It can push debris further into the nose, cause mucosal damage, bleeding, or even introduce germs. Instead, the nurse should advise the mother to use a bulb syringe for gentle suction if necessary.
Choice B Reason:
Leaving the yellow exudate on the circumcision site is actually recommended. This exudate is part of the normal healing process and does not need to be removed. It acts as a natural barrier to infection and will clear up as the circumcision heals.
Choice C Reason:
Cleaning the umbilical cord with tap water is generally considered safe and can help keep the area clean. However, the nurse should ensure that the mother dries the area thoroughly afterward to prevent moisture from promoting bacterial growth.
Choice D Reason:
Cleaning the newborn's eyes from the inner canthus outwards is the correct technique. It prevents contamination from the outer part of the eye to the inner part and helps to clear any discharge or debris effectively.
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