A nurse is assigned a breastfeeding woman who developed engorged breasts 3 days after birth.

The woman is greatly concerned about her painful breasts as it is causing her difficulty sleeping.

What should the nurse teach this woman who wants relief from the engorgement?

Choice B rationale

Any nipple discharge in a non lactating woman, especially if it is yellow, bloody, or serosanguinous, is abnormal and requires further investigation by a healthcare provider. While some hormonal changes occur during the menstrual cycle, spontaneous discharge is not a standard finding and could indicate an intraductal papilloma, infection, or malignancy. Patients must be taught that the only normal nipple discharge is breast milk during or after pregnancy. Recognizing and reporting abnormal discharge is a critical component of breast health education.

Choice C rationale

Performing a breast self examination at the same time each month, specifically several days after the menstrual period ends, is the correct technique. During this time, hormonal stimulation of the breast tissue is at its lowest, meaning the breasts are less likely to be tender or lumpy due to normal cyclic changes. This consistency allows the woman to become familiar with her normal breast tissue, making it easier to identify any new or unusual changes that may occur.

Choice D rationale

Using a systematic approach, such as a circular motion, vertical strip, or wedge pattern, ensures that all breast tissue, including the area under the nipple, is thoroughly palpated. Consistency in the method used helps the patient cover the entire breast area without missing any spots. Teaching a set way to perform the exam increases the likelihood of detecting small changes in the consistency or structure of the breast tissue, which is the primary goal of the self examination.

Choice A rationale

The axillary area, or armpit, contains the Tail of Spence, which is an extension of breast tissue where a significant percentage of breast cancers can develop. Including this area in a self examination is vital because lymph nodes in the axilla are often the first site of metastasis for breast malignancies. Patients should be instructed to feel for any lumps, thickening, or hard knots in the armpit to ensure a comprehensive assessment of all potential areas where breast pathology might arise.

Choice A rationale

Inserting an internal monitor, such as a fetal scalp electrode or intrauterine pressure catheter, is an invasive procedure typically reserved for situations where external monitoring is inadequate or when the fetal status is non-reassuring. The description provided matches early decelerations, which are considered a benign finding. There is no clinical indication to move to internal monitoring when the current tracing shows a normal, expected physiological response to head compression during the active phase of labor.

Choice B rationale

The description of the fetal heart rate decelerating at the onset of contractions and returning to baseline before the contraction ends is the classic definition of early decelerations. These are caused by fetal head compression, which triggers a vagal response. They are considered a reassuring sign and do not indicate fetal distress or hypoxia. Therefore, the appropriate nursing action is to document the finding as a normal part of the labor process without requiring intervention.

Choice C rationale

Changing the woman's position is a common intervention for variable decelerations, which are caused by cord compression, or late decelerations, which are caused by uteroplacental insufficiency. However, early decelerations do not require intrauterine resuscitation because they are not associated with decreased fetal oxygenation. While frequent position changes are generally good for labor progress, it is not a required corrective action for early decelerations, as they are a normal physiological occurrence during fetal descent.

Choice D rationale

Discontinuing the Oxytocin infusion is an intervention used when there is tachysystole or a non-reassuring fetal heart rate pattern, such as repetitive late decelerations or prolonged decelerations. Since early decelerations are benign and signify head compression rather than fetal distress, there is no need to stop the induction. The nurse should continue to monitor the patient and the infusion, as the fetal heart rate pattern described does not indicate a need for emergency measures or cessation.